Basic Information
| Provider Information | |||||||||
| NPI: | 1316305501 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KCBS VENTURES, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | METRO ER SOUTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4143 | ||||||||
| Address2: | |||||||||
| City: | MIDLAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 797044143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4326956932 | ||||||||
| FaxNumber: | 4326956934 | ||||||||
| Practice Location | |||||||||
| Address1: | 4438 S CLACK ST | ||||||||
| Address2: | |||||||||
| City: | ABILENE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 796063634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4326956932 | ||||||||
| FaxNumber: | 4326956934 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2016 | ||||||||
| LastUpdateDate: | 02/03/2016 | ||||||||
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| AuthorizedOfficialLastName: | CHOI | ||||||||
| AuthorizedOfficialFirstName: | KYUNGHO | ||||||||
| AuthorizedOfficialMiddleName: | SCOTT | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4326956932 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D., F.A.A.E.M. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
No ID Information.