1588115000 NPI number — GRENE VISION GROUP LLC

Table of content: (NPI 1588115000)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588115000 NPI number — GRENE VISION GROUP LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRENE VISION GROUP 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:
6
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:
1588115000
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/19/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1851 N WEBB RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WICHITA
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
67206-3413
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
316-858-3831
Provider Business Mailing Address Fax Number:
316-858-3830

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5231 E CENTRAL AVE
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
WICHITA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67208-4195
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
316-858-3831
Provider Business Practice Location Address Fax Number:
316-858-3830
Provider Enumeration Date:
10/19/2016

Additional Information

Authorized Official

Authorized Official Last Name:
DAVENPORT
Authorized Official First Name:
SHERYL
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
DIRECTOR CORPORATE ACCTS RECEIVABLE
Authorized Official Telephone Number:
316-858-3831

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 100217500A , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".




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