Healthcare Provider Details

I. General information

NPI: 1578595641
Provider Name (Legal Business Name): KNC MEDICAL SUPPLY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 10/26/2021
Certification Date: 10/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3931 W SLAUSON AVE
LOS ANGELES CA
90043-2976
US

IV. Provider business mailing address

4718 S MULLEN AVE
LOS ANGELES CA
90043-1718
US

V. Phone/Fax

Practice location:
  • Phone: 323-299-0837
  • Fax:
Mailing address:
  • Phone: 323-299-0837
  • Fax: 323-299-0839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberDME03143G
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License NumberDME03143G
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License NumberDME03143G
License Number StateCA

VIII. Authorized Official

Name: MR. OKEY OKAFOR
Title or Position: MANAGING DIRECTOR
Credential: N/A
Phone: 323-299-0837