Healthcare Provider Details

I. General information

NPI: 1386071397
Provider Name (Legal Business Name): KSM CORPORATE HOLDINGS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2013
Last Update Date: 04/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9430 W LAKE MEAD BLVD SUITE 3
LAS VEGAS NV
89134-8338
US

IV. Provider business mailing address

9430 W LAKE MEAD BLVD SUITE 3
LAS VEGAS NV
89134-8338
US

V. Phone/Fax

Practice location:
  • Phone: 709-998-2118
  • Fax:
Mailing address:
  • Phone: 709-998-2118
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number1016002025-001
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number1016002025-001
License Number StateNV

VIII. Authorized Official

Name: MR. KEVIN MICHAEL MCMANUS
Title or Position: ONWER
Credential:
Phone: 702-497-7112