Provider Demographics
NPI:1225689144
Name:KSJGQ LLC
Entity Type:Organization
Organization Name:KSJGQ LLC
Other - Org Name:KSJGQ
Other - Org Type:Doing Business As
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:IDIGBE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-636-0418
Mailing Address - Street 1:9607 WALNUT ST APT 11104
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243-2363
Mailing Address - Country:US
Mailing Address - Phone:214-636-0418
Mailing Address - Fax:
Practice Address - Street 1:9009 WHITE ROCK TRL
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75238-3347
Practice Address - Country:US
Practice Address - Phone:214-636-0418
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-23
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty