1710172473 NPI number — SEQUEL OF KANSAS, LLC

Table of content: (NPI 1710172473)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710172473 NPI number — SEQUEL OF KANSAS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SEQUEL OF KANSAS, 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:
Provider Other Organization Name Type Code:
6
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:
1710172473
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/30/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1131 EAGLETREE LANE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HUNTSVILLE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35801
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-880-3339
Provider Business Mailing Address Fax Number:
256-880-7026

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2050 W. 11TH ST N,
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:
67203
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
316-267-5710
Provider Business Practice Location Address Fax Number:
316-267-5710
Provider Enumeration Date:
09/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SELL
Authorized Official First Name:
HEATHER
Authorized Official Middle Name:
D.
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
316-267-5710

Provider Taxonomy Codes

  • Taxonomy code: 323P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 323P00000X , with the licence number: 62020 , 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: 200540330B , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 128807500 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".




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