1437563822 NPI number — ANITA SAMPSON LAC, KCGC

Table of content: ANITA SAMPSON LAC, KCGC (NPI 1437563822)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437563822 NPI number — ANITA SAMPSON LAC, KCGC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SAMPSON
Provider First Name:
ANITA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LAC, KCGC
Provider Gender Code:
F

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:
1437563822
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/27/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1805 S. OHIO ST.
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:
67402-2117
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
785-825-6224
Provider Business Mailing Address Fax Number:
785-827-7895

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1804 GLENDALE
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:
67401-6601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
785-825-6224
Provider Business Practice Location Address Fax Number:
785-825-1191
Provider Enumeration Date:
06/13/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  282 , 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: 100106710 R , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".




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