Healthcare Provider Details

I. General information

NPI: 1114757531
Provider Name (Legal Business Name): KSP HEALTH-VA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2024
Last Update Date: 08/02/2024
Certification Date: 08/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8001 FRANKLIN FARMS DR RM 127
HENRICO VA
23229-5100
US

IV. Provider business mailing address

8001 FRANKLIN FARMS DR RM 127
HENRICO VA
23229-5100
US

V. Phone/Fax

Practice location:
  • Phone: 804-282-9133
  • Fax: 804-282-9135
Mailing address:
  • Phone: 804-282-9133
  • Fax: 804-282-9135

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

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