1710252390 NPI number — CENTRAL CARE, PA

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 1710252390 NPI number — CENTRAL CARE, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTRAL CARE, PA
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:
1710252390
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 256
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:
67402-0256
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
785-823-0633
Provider Business Mailing Address Fax Number:
844-854-4662

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9300 E 29TH ST N
Provider Second Line Business Practice Location Address:
STE 315
Provider Business Practice Location Address City Name:
WICHITA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67226-2182
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
316-771-5896
Provider Business Practice Location Address Fax Number:
316-201-3055
Provider Enumeration Date:
03/15/2012

Additional Information

Authorized Official

Authorized Official Last Name:
CLOYD
Authorized Official First Name:
STACY
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING MANAGER
Authorized Official Telephone Number:
785-823-0633

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 200480600F , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100143020C , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".




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