MEDICARE: KVGP MEDICAL

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	332BX2000X	Oxygen Equipment & Supplies (DME)

General Provider Information

NPI Number	:	1841652062
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KVGP MEDICAL

Provider Business Mailing Address
First Line	:	3260 FOUNTAIN FALLS WAY
Second Line	:	#2075
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89032-2225
Country	:	US
Telephone Number	:	702-413-3647
Fax Number	:

Provider Business Practice Location Address
First Line	:	3260 FOUNTAIN FALLS WAY
Second Line	:	#2075
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89032-2225
Country	:	US
Telephone Number	:	702-413-3647
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	KOBUNA E VICKERS
Credential	:
Telephone Number	:	702-413-3647

Provider Enumeration Date	:	03/26/2016
Last Update Date	:	03/26/2016

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