1013070937 NPI number — KMM ENTERPRISES INC

Table of content: DR. IGNACIO R RODRIGUEZ MD (NPI 1306935176)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013070937 NPI number — KMM ENTERPRISES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KMM ENTERPRISES INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
LIVE WELL MEDICAL SUPPLY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013070937
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1901 DEERBROOK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TYLER
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75703-5972
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-561-5896
Provider Business Mailing Address Fax Number:
903-561-5887

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1901 DEERBROOK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TYLER
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75703-5972
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-561-5896
Provider Business Practice Location Address Fax Number:
903-561-5887
Provider Enumeration Date:
12/19/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
FERGUSON
Authorized Official First Name:
TRENTON
Authorized Official Middle Name:
K
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
903-530-3912

Provider Taxonomy Codes

  • Taxonomy code: 332BX2000X , with the licence number:  0093289 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)