MEDICARE: KANAWHA MEDICAL SUPPLY, INC.

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	332BC3200X	Customized Equipment (DME)	0206008452	VA

General Provider Information

NPI Number	:	1629133533
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KANAWHA MEDICAL SUPPLY, INC.

Provider Business Mailing Address
First Line	:	7009 FOREST HILL AVE
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23225-1607
Country	:	US
Telephone Number	:	804-330-5743
Fax Number	:	804-330-7149

Provider Business Practice Location Address
First Line	:	7009 FOREST HILL AVE
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23225-1607
Country	:	US
Telephone Number	:	804-330-5743
Fax Number	:	804-330-7149

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	DYANE B PERGERSON
Credential	:
Telephone Number	:	804-330-5743

Provider Enumeration Date	:	12/22/2006
Last Update Date	:	08/22/2020

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