Healthcare Provider Details

I. General information

NPI: 1538305198
Provider Name (Legal Business Name): KCAMLAED MEDICAL SUPPLY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/31/2008
Last Update Date: 12/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16900 LATHROP AVE
HARVEY IL
60426-6033
US

IV. Provider business mailing address

15341 4TH AVE
PHOENIX IL
60426-2620
US

V. Phone/Fax

Practice location:
  • Phone: 708-596-5671
  • Fax: 708-596-5623
Mailing address:
  • Phone: 708-333-2498
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BN1400X
TaxonomyNursing Facility Supplies (DME)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: MR. SAMUEL C MACK
Title or Position: CEO
Credential:
Phone: 708-333-2498