Healthcare Provider Details

I. General information

NPI: 1235676495
Provider Name (Legal Business Name): KEJ SURGICAL SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2017
Last Update Date: 01/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2770 HOLLY RIDGE CIR
MARIETTA GA
30062-4602
US

IV. Provider business mailing address

PO BOX 670132
MARIETTA GA
30066-0119
US

V. Phone/Fax

Practice location:
  • Phone: 214-227-2457
  • Fax: 214-764-0880
Mailing address:
  • Phone: 214-227-2457
  • Fax: 214-764-0880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number16-399
License Number StateGA

VIII. Authorized Official

Name: MR. MICHAEL E JOHNSON
Title or Position: OWNER
Credential: SAC
Phone: 214-227-2457