Healthcare Provider Details

I. General information

NPI: 1396315487
Provider Name (Legal Business Name): KJB ANESTHESIA, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2021
Last Update Date: 06/30/2021
Certification Date: 06/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 S COULTER ST
AMARILLO TX
79106-1781
US

IV. Provider business mailing address

PO BOX 6467
FLORENCE SC
29502-6467
US

V. Phone/Fax

Practice location:
  • Phone: 866-877-2762
  • Fax: 866-992-7144
Mailing address:
  • Phone: 866-877-2762
  • Fax: 866-992-7144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: KELLY J BLACK
Title or Position: OWNER
Credential: CRNA
Phone: 866-877-2762