=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346274230
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KCS MEDICAL HOME CARE SUPPLIES INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 ETOWAH TRACE
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30214
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-716-7678
-----------------------------------------------------
Fax | 770-716-1814
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 ETOWAH TRACE
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30214
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-716-7678
-----------------------------------------------------
Fax | 770-716-1814
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | MRS. LISTRA GOPAUL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 770-716-7678
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------