Provider Demographics
NPI:1982890653
Name:KC HEALTHCARE SUPPLIES LLC
Entity Type:Organization
Organization Name:KC HEALTHCARE SUPPLIES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHINWE
Authorized Official - Middle Name:
Authorized Official - Last Name:O'KOLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-377-9660
Mailing Address - Street 1:5425 SUGARLOAF PKWY
Mailing Address - Street 2:SUITE #1100
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-5764
Mailing Address - Country:US
Mailing Address - Phone:678-377-9660
Mailing Address - Fax:678-377-9566
Practice Address - Street 1:5425 SUGARLOAF PKWY
Practice Address - Street 2:SUITE#1100
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-5764
Practice Address - Country:US
Practice Address - Phone:678-377-9660
Practice Address - Fax:678-377-9566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-17
Last Update Date:2011-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA07072500332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA21677 PARENT ID 2292OtherCARECENTRIX
GA645147770AMedicaid
GA=========OtherBLUE CROSS AND BLUE SHIELD .
GA645147770AMedicaid
GA6025790001Medicare PIN
GA645147770AMedicaid