MEDICARE: KIH ADVANCED KARE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QH0100X	Health Service Clinic/Center
2	363L00000X	Nurse Practitioner

General Provider Information

NPI Number	:	1861082901
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIH ADVANCED KARE, LLC

Provider Business Mailing Address
First Line	:	10281 CORPORATE DR
Second Line	:
City	:	GULFPORT
State	:	MS
Zip	:	39503-4603
Country	:	US
Telephone Number	:	228-604-2155
Fax Number	:

Provider Business Practice Location Address
First Line	:	10281 CORPORATE DR
Second Line	:
City	:	GULFPORT
State	:	MS
Zip	:	39503-4603
Country	:	US
Telephone Number	:	228-604-2155
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	MR. CHAD BLALACK
Credential	:
Telephone Number	:	228-861-4218

Provider Enumeration Date	:	01/22/2021
Last Update Date	:	01/22/2021

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Directions to “KIH ADVANCED KARE, LLC ” Practice Location

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