Healthcare Provider Details

I. General information

NPI: 1023813797
Provider Name (Legal Business Name): KS TKO ANESTHESIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2025
Last Update Date: 02/17/2025
Certification Date: 02/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1721 MAGNAVOX WAY STE A
FORT WAYNE IN
46804-1537
US

IV. Provider business mailing address

5716 W 400 S
HUNTINGTON IN
46750-9135
US

V. Phone/Fax

Practice location:
  • Phone: 260-250-0001
  • Fax:
Mailing address:
  • Phone: 208-681-8157
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number StateNULL

VIII. Authorized Official

Name: KENDRA SMITH
Title or Position: CEO
Credential: CRNA
Phone: 208-681-8157