Provider Demographics
NPI:1891916367
Name:KIMBO MEDICAL DISTRIBUTOR
Entity Type:Organization
Organization Name:KIMBO MEDICAL DISTRIBUTOR
Other - Org Name:KIMBO MEDICAL DISTRIBUTOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:C.E.O
Authorized Official - Prefix:MR
Authorized Official - First Name:GODWILL
Authorized Official - Middle Name:TABE
Authorized Official - Last Name:TAMUNANG
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:310-834-9574
Mailing Address - Street 1:407 N AVALON BLVD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:CA
Mailing Address - Zip Code:90744-5803
Mailing Address - Country:US
Mailing Address - Phone:310-834-9574
Mailing Address - Fax:866-398-5898
Practice Address - Street 1:407 N AVALON BLVD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:CA
Practice Address - Zip Code:90744-5803
Practice Address - Country:US
Practice Address - Phone:310-834-9574
Practice Address - Fax:866-398-5898
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44548332B00000X, 332BP3500X, 332BX2000X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACMCSUBT9EMedicaid
CA5756720001Medicare NSC