Healthcare Provider Details

I. General information

NPI: 1689519316
Provider Name (Legal Business Name): KODIAK HME LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2026
Last Update Date: 04/20/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2112 E 4TH ST STE 104A
SANTA ANA CA
92705-3849
US

IV. Provider business mailing address

10 MOCKINGBIRD LN
TRABUCO CANYON CA
92679-5336
US

V. Phone/Fax

Practice location:
  • Phone: 949-735-0216
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: MR. MONT MITTLEMAN
Title or Position: CEO
Credential:
Phone: 949-735-0216