Provider Demographics
NPI:1962512087
Name:KC MEDICAL SUPPLIES
Entity Type:Organization
Organization Name:KC MEDICAL SUPPLIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHEENA
Authorized Official - Middle Name:RENNE
Authorized Official - Last Name:SHELTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-234-0700
Mailing Address - Street 1:1605 JUDSON RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-3662
Mailing Address - Country:US
Mailing Address - Phone:903-234-0700
Mailing Address - Fax:903-234-0701
Practice Address - Street 1:1605 JUDSON RD
Practice Address - Street 2:SUITE D
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-3662
Practice Address - Country:US
Practice Address - Phone:903-234-0700
Practice Address - Fax:903-234-0701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0068887332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1647179Medicaid
TX162672302OtherMEDICAID
TX162672301Medicaid
LA1647179Medicaid