Provider Demographics
NPI:1770134967
Name:KKCL HEALTHCARE LLC
Entity type:Organization
Organization Name:KKCL HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KRYSTAL
Authorized Official - Middle Name:K
Authorized Official - Last Name:LAUER
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:804-441-0447
Mailing Address - Street 1:1527 SUNFLOWER FIELDS DR
Mailing Address - Street 2:
Mailing Address - City:RUCKERSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22968-1510
Mailing Address - Country:US
Mailing Address - Phone:804-441-0447
Mailing Address - Fax:804-282-9135
Practice Address - Street 1:1527 SUNFLOWER FIELDS DR
Practice Address - Street 2:
Practice Address - City:RUCKERSVILLE
Practice Address - State:VA
Practice Address - Zip Code:22968-1510
Practice Address - Country:US
Practice Address - Phone:804-441-0447
Practice Address - Fax:804-282-9135
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-27
Last Update Date:2019-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty