1003362732 NPI number — MOC WICHITA, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003362732 NPI number — MOC WICHITA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOC WICHITA, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
THE HEALTHCARE RESORT OF WICHITA
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003362732
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/22/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14300 CLAY TERRACE BLVD.
Provider Second Line Business Mailing Address:
SUITE 257
Provider Business Mailing Address City Name:
CARMEL
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46032
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-582-6200
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7057 WEST VILLAGE CIRCLE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WICHITA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67205
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
316-977-7015
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/01/2016

Additional Information

Authorized Official

Authorized Official Last Name:
TURNER
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
EZEKIEL
Authorized Official Title or Position:
CEO/MANAGER
Authorized Official Telephone Number:
317-460-0324

Provider Taxonomy Codes

  • Taxonomy code: 310400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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