Healthcare Provider Details

I. General information

NPI: 1265783070
Provider Name (Legal Business Name): ANGELA KRELO SURGICAL/MEDICAL AS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2012
Last Update Date: 09/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 W. JACKSON SUITE 402
CARBONDALE IL
62901
US

IV. Provider business mailing address

500 RUSHING DRIVE
HERRIN IL
62948
US

V. Phone/Fax

Practice location:
  • Phone: 618-529-4711
  • Fax: 618-998-8809
Mailing address:
  • Phone: 618-998-8808
  • Fax: 618-998-8809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: