1750325197 NPI number — NORTHEAST KANSAS CENTER FOR HEALTH AND WELLNESS, INC.

Table of content: (NPI 1750325197)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750325197 NPI number — NORTHEAST KANSAS CENTER FOR HEALTH AND WELLNESS, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHEAST KANSAS CENTER FOR HEALTH AND WELLNESS, INC.
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:
1750325197
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
240 W 18TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HORTON
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66439-1245
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
785-486-2642
Provider Business Mailing Address Fax Number:
785-486-2842

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
240 W 18TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HORTON
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66439-1245
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
785-486-2642
Provider Business Practice Location Address Fax Number:
785-486-2842
Provider Enumeration Date:
06/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WHITE
Authorized Official First Name:
DALE
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
785-486-2642

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  H-007-002 , 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: 426980 . This is a "BLUE SHIELD" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 161636 . This is a "BLUE SHIELD" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 426996 . This is a "BLUE SHIELD" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 664990 . This is a "FIRST GUARD HEALTH PLAN" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 927587 . This is a "FIRST GUARD HEALTH PLAN" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 928432 . This is a "FIRST GUARD HEALTH PLAN" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 105445 . This is a "BLUE SHIELD" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 042154 . This is a "BLUE SHIELD" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".




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