1245390251 NPI number — COTTON O'NEIL CLINIC RECOVABLE TRUST

Table of content: (NPI 1245390251)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245390251 NPI number — COTTON O'NEIL CLINIC RECOVABLE TRUST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COTTON O'NEIL CLINIC RECOVABLE TRUST
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:
COTTON O'NEIL BEHAVIORAL HEALTH
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:
1245390251
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/19/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
901 SW GARFIELD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TOPEKA
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66606-1670
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
785-354-9591
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3707 SW 6TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TOPEKA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66606-2084
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
785-270-4600
Provider Business Practice Location Address Fax Number:
785-270-4601
Provider Enumeration Date:
12/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
YOCUM
Authorized Official First Name:
DEBRA
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
785-354-9591

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2084P0802X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0804X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0805X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 100217350D , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 110661 . This is a "PTAN" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".




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