Provider Demographics
NPI:1942221973
Name:KAVANAUGH SUPPLIES LLC
Entity Type:Organization
Organization Name:KAVANAUGH SUPPLIES LLC
Other - Org Name:FREEDOM HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:KAVANAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-296-6763
Mailing Address - Street 1:22 98 PLACE BLVD
Mailing Address - Street 2:SUITE 10
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-8603
Mailing Address - Country:US
Mailing Address - Phone:601-296-6763
Mailing Address - Fax:601-296-6764
Practice Address - Street 1:22 98 PLACE BLVD
Practice Address - Street 2:SUITE 10
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-8603
Practice Address - Country:US
Practice Address - Phone:601-296-6763
Practice Address - Fax:601-296-6764
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2009-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS037068103332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08876259Medicaid
MS5072340001Medicare NSC