MEDICARE: KOVINE 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	332B00000X	Durable Medical Equipment & Medical Supplies	600442227	NC

General Provider Information

NPI Number	:	1699776088
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KOVINE MEDICAL SUPPLY, INC.

Provider Business Mailing Address
First Line	:	620 S ELM ST
Second Line	:	STE 374
City	:	GREENSBORO
State	:	NC
Zip	:	27406-1398
Country	:	US
Telephone Number	:	336-398-9343
Fax Number	:	336-389-9334

Provider Business Practice Location Address
First Line	:	620 S ELM ST
Second Line	:	STE 374
City	:	GREENSBORO
State	:	NC
Zip	:	27406-1398
Country	:	US
Telephone Number	:	336-398-9343
Fax Number	:	336-389-9334

Authorized Official
Title or Position	:	OWNER
Name	:	MR. KPOTO OKON ISANGEDIGHI
Credential	:
Telephone Number	:	336-389-9343

Provider Enumeration Date	:	08/09/2005
Last Update Date	:	03/04/2010

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