Healthcare Provider Details

I. General information

NPI: 1366141590
Provider Name (Legal Business Name): KEG SURGICAL ASSISTING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2023
Last Update Date: 06/11/2023
Certification Date: 06/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4905 W OLD POTASH HWY
GRAND ISLAND NE
68803-9026
US

IV. Provider business mailing address

4905 W OLD POTASH HWY
GRAND ISLAND NE
68803-9026
US

V. Phone/Fax

Practice location:
  • Phone: 308-379-6727
  • Fax:
Mailing address:
  • Phone: 308-379-6727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: KYRRA GRIFFIS
Title or Position: CST, CSFA
Credential: CST, CSFA
Phone: 308-379-6727