=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366141590
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KEG SURGICAL ASSISTING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2023
-----------------------------------------------------
Last Update Date | 06/11/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4905 W OLD POTASH HWY
-----------------------------------------------------
City | GRAND ISLAND
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68803-9026
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 308-379-6727
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4905 W OLD POTASH HWY
-----------------------------------------------------
City | GRAND ISLAND
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68803-9026
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 308-379-6727
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CST, CSFA
-----------------------------------------------------
Name | KYRRA GRIFFIS
-----------------------------------------------------
Credential | CST, CSFA
-----------------------------------------------------
Telephone | 308-379-6727
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 246ZC0007X
-----------------------------------------------------
Taxonomy Name | Surgical Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------