Healthcare Provider Details

I. General information

NPI: 1679926620
Provider Name (Legal Business Name): JKN MEDICAL SUPPORT GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2016
Last Update Date: 07/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13250 EMILY RD APT 1006
DALLAS TX
75240-5953
US

IV. Provider business mailing address

13250 EMILY RD APT 1006
DALLAS TX
75240-5953
US

V. Phone/Fax

Practice location:
  • Phone: 316-409-3022
  • Fax:
Mailing address:
  • Phone: 316-409-3022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State

VIII. Authorized Official

Name: KENNETH BETHEL
Title or Position: OWNER
Credential:
Phone: 316-409-3022