Basic Information
| Provider Information | |||||||||
| NPI: | 1053459818 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KB MANAGEMENT SERVICES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1121 S 4TH ST | ||||||||
| Address2: | |||||||||
| City: | HARTSVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295500700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436399509 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1304 W BOBO NEWSOM HWY | ||||||||
| Address2: | |||||||||
| City: | HARTSVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295504710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433394600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BALICH | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8436399509 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 011678 | SC | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | GP3064 | 05 | SC | MEDICAID |