Provider Demographics
NPI:1003499708
Name:COMMUNITY HEALTH CENTER OF SOUTHEAST KANSAS, INC.
Entity Type:Organization
Organization Name:COMMUNITY HEALTH CENTER OF SOUTHEAST KANSAS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL COUNSEL
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:SPENCER
Authorized Official - Last Name:CREITZ
Authorized Official - Suffix:
Authorized Official - Credentials:JD
Authorized Official - Phone:620-240-5015
Mailing Address - Street 1:PO BOX 1832
Mailing Address - Street 2:
Mailing Address - City:PITTSBURG
Mailing Address - State:KS
Mailing Address - Zip Code:66762-1832
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:401 WOODLAND HILLS BLVD
Practice Address - Street 2:
Practice Address - City:FORT SCOTT
Practice Address - State:KS
Practice Address - Zip Code:66701-8797
Practice Address - Country:US
Practice Address - Phone:620-223-8040
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-30
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSKDADS033021HOtherSUBSTANCE USE AND ADDICTIONS SERVICES CERTIFICATE