1104993641 NPI number — PROVIDENCE FAMILY HEALTH CARE LLC

Table of content: (NPI 1104993641)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104993641 NPI number — PROVIDENCE FAMILY HEALTH CARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROVIDENCE FAMILY HEALTH CARE 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:
1104993641
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/01/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
211 GREENWAY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALINA
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
67401-3533
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
785-309-1166
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
211 GREENWAY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALINA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67401-3533
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
785-309-1166
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BROWN
Authorized Official First Name:
CHRISTOPHER
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
785-827-6400

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  0429899 , 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: 200263350A , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com