Provider Demographics
NPI:1306932736
Name:KOUCH MEDICAL LLC
Entity type:Organization
Organization Name:KOUCH MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CHIBUIKEM
Authorized Official - Middle Name:
Authorized Official - Last Name:IHEANACHO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-421-1845
Mailing Address - Street 1:1325 TRAVIS BLVD
Mailing Address - Street 2:STE B
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-4611
Mailing Address - Country:US
Mailing Address - Phone:707-421-8145
Mailing Address - Fax:707-421-8155
Practice Address - Street 1:1325 TRAVIS BLVD
Practice Address - Street 2:STE B
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-4611
Practice Address - Country:US
Practice Address - Phone:707-421-8145
Practice Address - Fax:707-421-8155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5386280001Medicare NSC