Healthcare Provider Details

I. General information

NPI: 1245586536
Provider Name (Legal Business Name): JEB MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2012
Last Update Date: 09/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 CLAY ST
KANSAS CITY MO
64116-4026
US

IV. Provider business mailing address

1215 CLAY ST
KANSAS CITY MO
64116-4026
US

V. Phone/Fax

Practice location:
  • Phone: 816-695-4929
  • Fax:
Mailing address:
  • Phone: 816-695-4929
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberLC1242724
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code364SM0705X
TaxonomyMedical-Surgical Clinical Nurse Specialist
License Number
License Number State

VIII. Authorized Official

Name: MR. BRIAN A KING
Title or Position: PRINCIPAL
Credential:
Phone: 816-695-4929