Healthcare Provider Details

I. General information

NPI: 1154167666
Provider Name (Legal Business Name): KSP HEALTH - TN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2024
Last Update Date: 07/03/2024
Certification Date: 07/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 AGNES RD STE 200
KNOXVILLE TN
37919-6306
US

IV. Provider business mailing address

6446 E CENTRAL AVE STE 183
WICHITA KS
67206-1923
US

V. Phone/Fax

Practice location:
  • Phone: 316-516-2853
  • Fax:
Mailing address:
  • Phone: 316-516-2853
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. MUTHUKUMAR VELLAICHAMY
Title or Position: SOLE MEMBER
Credential: MD
Phone: 316-516-2853