Healthcare Provider Details

I. General information

NPI: 1942205943
Provider Name (Legal Business Name): KENTUCKY MEDICAL SUPPLY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 06/15/2020
Certification Date: 06/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 CASTLE RIDGE DR
EDMONTON KY
42129
US

IV. Provider business mailing address

3325 BARTLETT BLVD
ORLANDO FL
32811-6428
US

V. Phone/Fax

Practice location:
  • Phone: 270-432-0957
  • Fax: 270-432-0957
Mailing address:
  • Phone: 407-206-0040
  • Fax: 407-206-0010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number177855
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number175293
License Number StateKY

VIII. Authorized Official

Name: MR. STEPHEN P GRIGGS
Title or Position: CEO/ PRESIDENT
Credential:
Phone: 407-206-0040