MEDICARE: JEB MEDICAL LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AS0400X	Surgical Physician Assistant
2	364SM0705X	Medical-Surgical Clinical Nurse Specialist
3	332B00000X	Durable Medical Equipment & Medical Supplies	LC1242724	MO

General Provider Information

NPI Number	:	1245586536
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JEB MEDICAL LLC

Provider Business Mailing Address
First Line	:	1215 CLAY ST
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64116-4026
Country	:	US
Telephone Number	:	816-695-4929
Fax Number	:

Provider Business Practice Location Address
First Line	:	1215 CLAY ST
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64116-4026
Country	:	US
Telephone Number	:	816-695-4929
Fax Number	:

Authorized Official
Title or Position	:	PRINCIPAL
Name	:	MR. BRIAN A KING
Credential	:
Telephone Number	:	816-695-4929

Provider Enumeration Date	:	07/24/2012
Last Update Date	:	09/14/2012

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