Basic Information
Provider Information | |||||||||
NPI: | 1962161299 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | KPB ANESTHESIA, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 400 10TH ST E | ||||||||
Address2: |   | ||||||||
City: | WACONIA | ||||||||
State: | MN | ||||||||
PostalCode: | 553874552 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9524429770 | ||||||||
FaxNumber: | 9524423620 | ||||||||
Practice Location | |||||||||
Address1: | 13772 DENVER WEST PKWY STE 100 | ||||||||
Address2: |   | ||||||||
City: | LAKEWOOD | ||||||||
State: | CO | ||||||||
PostalCode: | 804013139 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3032796600 | ||||||||
FaxNumber: | 9524423620 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/14/2021 | ||||||||
LastUpdateDate: | 12/14/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PRCHAL BELCHER | ||||||||
AuthorizedOfficialFirstName: | ANNA | ||||||||
AuthorizedOfficialMiddleName: | C | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER / PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 7063401023 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | CRNA | ||||||||
NPICertificationDate: | 12/14/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
No ID Information.