1750810933 NPI number — NOBLE CLINIC, 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 1750810933 NPI number — NOBLE CLINIC, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NOBLE CLINIC, 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:
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:
1750810933
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/14/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1007 S OLIVE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PITTSBURG
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66762-5622
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
620-249-5443
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1322 S BROADWAY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PITTSBURG
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66762-5836
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-249-5443
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/09/2017

Additional Information

Authorized Official

Authorized Official Last Name:
COULTER MORRELL
Authorized Official First Name:
MICHELLE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
620-249-5443

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  0759 , 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: 1104036110 . This is a "NPI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 12368901 . This is a "CAQH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1447684931 . This is a "NPI" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 1447684931 , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200442400D , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".




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