1255632840 NPI number — CAH ACQUISITION COMPANY 2 LLC

Table of content: (NPI 1255632840)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255632840 NPI number — CAH ACQUISITION COMPANY 2 LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CAH ACQUISITION COMPANY 2 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:
CHETOPA COMMUNITY CLINIC
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:
1255632840
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/16/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
800 BARKER DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OSWEGO
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
67356-9033
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
620-236-7351
Provider Business Mailing Address Fax Number:
620-236-7976

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
429 MAPLE STREET
Provider Second Line Business Practice Location Address:
BOX 106
Provider Business Practice Location Address City Name:
CHETOPA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67336
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-236-7351
Provider Business Practice Location Address Fax Number:
620-236-7976
Provider Enumeration Date:
11/12/2010

Additional Information

Authorized Official

Authorized Official Last Name:
COCHRAN
Authorized Official First Name:
BILLY
Authorized Official Middle Name:
D
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
620-795-2921

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X , with the licence number:  H050003 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 200570210D , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".




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