MEDICARE: JKN MEDICAL SUPPORT GROUP LLC

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
2	347C00000X	Private Vehicle

General Provider Information

NPI Number	:	1679926620
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JKN MEDICAL SUPPORT GROUP LLC

Provider Business Mailing Address
First Line	:	13250 EMILY RD APT 1006
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75240-5953
Country	:	US
Telephone Number	:	316-409-3022
Fax Number	:

Provider Business Practice Location Address
First Line	:	13250 EMILY RD APT 1006
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75240-5953
Country	:	US
Telephone Number	:	316-409-3022
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KENNETH BETHEL
Credential	:
Telephone Number	:	316-409-3022

Provider Enumeration Date	:	07/14/2016
Last Update Date	:	07/14/2016

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