Provider Demographics
NPI:1285254656
Name:KINETIC PROSTHETICS & MEDICAL SUPPLY
Entity type:Organization
Organization Name:KINETIC PROSTHETICS & MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMERON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-756-7073
Mailing Address - Street 1:3595 HIRAM DOUGLASVILLE HWY STE 102
Mailing Address - Street 2:
Mailing Address - City:HIRAM
Mailing Address - State:GA
Mailing Address - Zip Code:30141-4963
Mailing Address - Country:US
Mailing Address - Phone:678-653-8370
Mailing Address - Fax:404-492-8885
Practice Address - Street 1:3595 HIRAM DOUGLASVILLE HWY STE 102
Practice Address - Street 2:
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141-4963
Practice Address - Country:US
Practice Address - Phone:678-653-8370
Practice Address - Fax:404-492-8885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-25
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA7812720001OtherDMEPOS