Provider Demographics
NPI:1609215730
Name:KGC CRNA LLC
Entity Type:Organization
Organization Name:KGC CRNA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KANDEE
Authorized Official - Middle Name:GEORGETTE
Authorized Official - Last Name:COPPALA
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:321-759-4460
Mailing Address - Street 1:PO BOX 410580
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32941-0580
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3337 CAPPIO DR
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-1313
Practice Address - Country:US
Practice Address - Phone:321-759-4460
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-21
Last Update Date:2013-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 9217913367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL306690800Medicaid