Provider Demographics
NPI:1114757531
Name:KSP HEALTH-VA LLC
Entity type:Organization
Organization Name:KSP HEALTH-VA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MUTHUKUMAR
Authorized Official - Middle Name:
Authorized Official - Last Name:VELLAICHAMY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:316-516-2853
Mailing Address - Street 1:8001 FRANKLIN FARMS DR RM 127
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23229-5100
Mailing Address - Country:US
Mailing Address - Phone:804-282-9133
Mailing Address - Fax:804-282-9135
Practice Address - Street 1:8001 FRANKLIN FARMS DR RM 127
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23229-5100
Practice Address - Country:US
Practice Address - Phone:804-282-9133
Practice Address - Fax:804-282-9135
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-02
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Multi-Specialty