Provider Demographics
NPI:1972845634
Name:KINETIX MEDICAL EQUIPMENT, LLC
Entity Type:Organization
Organization Name:KINETIX MEDICAL EQUIPMENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:C
Authorized Official - Last Name:SUDDUTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-207-2711
Mailing Address - Street 1:PO BOX 520
Mailing Address - Street 2:
Mailing Address - City:ROLLING FORK
Mailing Address - State:MS
Mailing Address - Zip Code:39159-0520
Mailing Address - Country:US
Mailing Address - Phone:662-873-9222
Mailing Address - Fax:662-873-9221
Practice Address - Street 1:21 S FOURTH ST
Practice Address - Street 2:
Practice Address - City:ROLLING FORK
Practice Address - State:MS
Practice Address - Zip Code:39159-5146
Practice Address - Country:US
Practice Address - Phone:662-873-9222
Practice Address - Fax:662-873-9221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-20
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00440262Medicaid
MS00440262Medicaid