Provider Demographics
NPI:1346493269
Name:KSR MEDICAL LLC
Entity Type:Organization
Organization Name:KSR MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KHALED
Authorized Official - Middle Name:MOSTAFA
Authorized Official - Last Name:GHORAB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-239-4130
Mailing Address - Street 1:1015 W FERTITTA BLVD
Mailing Address - Street 2:
Mailing Address - City:LEESVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71446-4646
Mailing Address - Country:US
Mailing Address - Phone:337-239-4130
Mailing Address - Fax:337-238-9030
Practice Address - Street 1:1015 W FERTITTA BLVD
Practice Address - Street 2:
Practice Address - City:LEESVILLE
Practice Address - State:LA
Practice Address - Zip Code:71446-4646
Practice Address - Country:US
Practice Address - Phone:337-239-4130
Practice Address - Fax:337-238-9030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-23
Last Update Date:2008-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA202557261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA202557OtherLOUISIANA STATE LICENCE