1407144058 NPI number — HEALING WATERS WICHITA LC

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 1407144058 NPI number — HEALING WATERS WICHITA LC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEALING WATERS WICHITA LC
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:
1407144058
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/30/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
33 BUFORD VILLAGE WAY
Provider Second Line Business Mailing Address:
SUITE 325
Provider Business Mailing Address City Name:
BUFORD
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30518-8843
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-730-7780
Provider Business Mailing Address Fax Number:
678-730-7786

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2000 N ROCK RD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
WICHITA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67206-1201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
316-262-2995
Provider Business Practice Location Address Fax Number:
316-262-2546
Provider Enumeration Date:
07/18/2011

Additional Information

Authorized Official

Authorized Official Last Name:
GORECKI
Authorized Official First Name:
AMANDA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
316-262-2995

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 200468790A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 201097690A , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".




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