Healthcare Provider Details

I. General information

NPI: 1619579794
Provider Name (Legal Business Name): KS IOM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2020
Last Update Date: 11/18/2020
Certification Date: 11/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

918 E LAKECREST DR
ANDOVER KS
67002-9343
US

IV. Provider business mailing address

PO BOX 720762
NORMAN OK
73070-4590
US

V. Phone/Fax

Practice location:
  • Phone: 918-895-7680
  • Fax: 918-236-4646
Mailing address:
  • Phone: 918-895-7680
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: VALERIE SHEHAN
Title or Position: BILLING
Credential:
Phone: 918-895-7680