Provider Demographics
NPI:1487975603
Name:KSB MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:KSB MEDICAL GROUP, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:AUSTIN
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:FRAZIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-285-5513
Mailing Address - Street 1:PO BOX 841330
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64184-1330
Mailing Address - Country:US
Mailing Address - Phone:816-201-3331
Mailing Address - Fax:
Practice Address - Street 1:511 PALMYRA ST
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-1953
Practice Address - Country:US
Practice Address - Phone:815-284-2020
Practice Address - Fax:815-284-8326
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-22
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier