Healthcare Provider Details

I. General information

NPI: 1689694457
Provider Name (Legal Business Name): KSK ENTERPRISES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 03/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 E FOURTH ST. SUITE 200
SANTA ANA CA
92705
US

IV. Provider business mailing address

7900 BELFORT PARKWAY SUTIE 301
JACKSONVILLE FL
32256-6978
US

V. Phone/Fax

Practice location:
  • Phone: 714-939-7500
  • Fax: 714-939-7577
Mailing address:
  • Phone: 904-517-5500
  • Fax: 904-517-5501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS1200X
TaxonomySleep Disorder Diagnostic Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. JIM EVANGER
Title or Position: PRESIDENT
Credential:
Phone: 904-517-5500