Provider Demographics
NPI:1033218565
Name:HEALTHCORE CLINIC INC
Entity Type:Organization
Organization Name:HEALTHCORE CLINIC INC
Other - Org Name:CENTER FOR HEALTH AND WELLNESS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:LOVELADY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:316-691-0249
Mailing Address - Street 1:2707 EAST 21ST STREET NORTH
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67214-2249
Mailing Address - Country:US
Mailing Address - Phone:316-691-0249
Mailing Address - Fax:316-691-9939
Practice Address - Street 1:2707 EAST 21ST STREET NORTH
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-2249
Practice Address - Country:US
Practice Address - Phone:316-691-0249
Practice Address - Fax:316-691-9939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2015-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1033218565261QF0400X
KS07000887261QM0801X
KS07000882261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100321990Medicaid
KS100321990CMedicaid
KS100321990AMedicaid
KS100321990AMedicaid
KS100321990Medicaid