Healthcare Provider Details

I. General information

NPI: 1821088964
Provider Name (Legal Business Name): KOFFEL MEDICAL SUPPLY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1003 W PARK AVE
LIBERTYVILLE IL
60048-2550
US

IV. Provider business mailing address

1003 W PARK AVE
LIBERTYVILLE IL
60048-2550
US

V. Phone/Fax

Practice location:
  • Phone: 847-816-8000
  • Fax: 847-816-8606
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BD1200X
TaxonomyDialysis Equipment & Supplies (DME)
License Number
License Number StateIL

VIII. Authorized Official

Name: MR. JOHN W KOFFEL
Title or Position: PRESIDENT
Credential:
Phone: 847-816-8000