Provider Demographics
NPI:1962555938
Name:KINGDOM MEDICAL SUPPLY INC
Entity type:Organization
Organization Name:KINGDOM MEDICAL SUPPLY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:JIN
Authorized Official - Last Name:ZHAO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-751-0628
Mailing Address - Street 1:3900 GEARY BLVD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94118-3261
Mailing Address - Country:US
Mailing Address - Phone:415-751-0628
Mailing Address - Fax:415-751-0619
Practice Address - Street 1:3900 GEARY BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94118-3261
Practice Address - Country:US
Practice Address - Phone:415-751-0628
Practice Address - Fax:415-751-0619
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-21
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46267332B00000X, 332BC3200X, 332BP3500X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5927540001Medicare NSC