1982337705 NPI number — RADIANT FAMILY WELLNESS

Table of content: (NPI 1982337705)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982337705 NPI number — RADIANT FAMILY WELLNESS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RADIANT FAMILY WELLNESS
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:
1982337705
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/08/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17701 N US HIGHWAY 169
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SMITHVILLE
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64089-8609
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12744 S PFLUMM RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OLATHE
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66062-3664
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
913-322-0251
Provider Business Practice Location Address Fax Number:
816-817-4861
Provider Enumeration Date:
07/08/2022

Additional Information

Authorized Official

Authorized Official Last Name:
KREADY
Authorized Official First Name:
STACIE
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OFFICE MANAGE
Authorized Official Telephone Number:
913-322-0251

Provider Taxonomy Codes

  • Taxonomy code: 111NP0017X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 49738011 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 57465021 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 6031765 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".




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