Healthcare Provider Details

I. General information

NPI: 1588486328
Provider Name (Legal Business Name): KC SURGICAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2024
Last Update Date: 10/31/2024
Certification Date: 10/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4650 N CENTRAL AVE UNIT 166
PHOENIX AZ
85012-1071
US

IV. Provider business mailing address

21200 S LAGRANGE RD # 322
FRANKFORT IL
60423-2003
US

V. Phone/Fax

Practice location:
  • Phone: 480-702-4444
  • Fax: 844-427-2845
Mailing address:
  • Phone: 708-571-0398
  • Fax: 844-427-2845

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. KAYLA COFFEY
Title or Position: PRESIDENT
Credential: CSFA
Phone: 480-702-9444