=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154944114
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KEN DME MEDICAL SUPPLIES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/26/2020
-----------------------------------------------------
Last Update Date | 05/26/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1816 TULLY RD STE 235
-----------------------------------------------------
City | SAN JOSE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95122-4405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-667-3836
-----------------------------------------------------
Fax | 408-274-4878
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1816 TULLY RD STE 235
-----------------------------------------------------
City | SAN JOSE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95122-4405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-667-3836
-----------------------------------------------------
Fax | 408-274-4878
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN/OWNER
-----------------------------------------------------
Name | DR. THUY FRANK TRAN
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 408-667-3836
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------