Healthcare Provider Details

I. General information

NPI: 1528566544
Provider Name (Legal Business Name): KSA ENTERPRISES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2018
Last Update Date: 01/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2171 FAIR HILL DR
ALLEN TX
75013-5658
US

IV. Provider business mailing address

2171 FAIR HILL DR
ALLEN TX
75013-5658
US

V. Phone/Fax

Practice location:
  • Phone: 469-231-5085
  • Fax:
Mailing address:
  • Phone: 469-231-5085
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: PURNIMA KUMAR
Title or Position: OFFICE ADMINISTRATOR
Credential:
Phone: 469-231-5085