MEDICARE: KERN VALLEY MEDICAL SUPPLY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1023007762
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KERN VALLEY MEDICAL SUPPLY

Provider Business Mailing Address
First Line	:	5213 LAKE ISABELLA BLVD
Second Line	:
City	:	LAKE ISABELLA
State	:	CA
Zip	:	93240-9642
Country	:	US
Telephone Number	:	760-379-8111
Fax Number	:	760-379-1411

Provider Business Practice Location Address
First Line	:	5213 LAKE ISABELLA BLVD
Second Line	:
City	:	LAKE ISABELLA
State	:	CA
Zip	:	93240-9642
Country	:	US
Telephone Number	:	760-379-8111
Fax Number	:	760-379-1411

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. WENDY JUNE RUSSELL
Credential	:
Telephone Number	:	760-379-8111

Provider Enumeration Date	:	10/16/2005
Last Update Date	:	08/12/2008

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Directions to “KERN VALLEY MEDICAL SUPPLY ” Practice Location

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