Healthcare Provider Details

I. General information

NPI: 1952367807
Provider Name (Legal Business Name): KLG MOBILE INTENSIVE CO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 03/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1516 B SOUTH LINCOLN AVENUE
SALEM OH
44460-4249
US

IV. Provider business mailing address

1516 B SOUTH LINCOLN AVENUE
SALEM OH
44460-4249
US

V. Phone/Fax

Practice location:
  • Phone: 330-337-4555
  • Fax: 330-337-4552
Mailing address:
  • Phone: 330-337-4555
  • Fax: 330-337-4552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number150062
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number155075
License Number StateOH

VIII. Authorized Official

Name: MR. KARL LEE GRIGGS
Title or Position: PRESIDENT CEO
Credential:
Phone: 330-337-4555