=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689519316
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KODIAK HME LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/20/2026
-----------------------------------------------------
Last Update Date | 04/20/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2112 E 4TH ST STE 104A
-----------------------------------------------------
City | SANTA ANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92705-3849
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-735-0216
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10 MOCKINGBIRD LN
-----------------------------------------------------
City | TRABUCO CANYON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92679-5336
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. MONT MITTLEMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 949-735-0216
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332BC3200X
-----------------------------------------------------
Taxonomy Name | Customized Equipment (DME)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------