=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306543889
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 4KAS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/14/2023
-----------------------------------------------------
Last Update Date | 02/22/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1428 KENILWORTH DR
-----------------------------------------------------
City | LANSING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48917-2048
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-803-0812
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1428 KENILWORTH DR
-----------------------------------------------------
City | LANSING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48917-2048
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-803-0812
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AUTHORIZED OFFICIAL
-----------------------------------------------------
Name | MUHAMMAD KANG
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 517-803-0812
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0131X
-----------------------------------------------------
Taxonomy Name | Foot Surgery Podiatrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------