Provider Demographics
NPI:1164464525
Name:ARK CITY CLINIC P A
Entity Type:Organization
Organization Name:ARK CITY CLINIC P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:RUYLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:620-442-2100
Mailing Address - Street 1:510 W RADIO LN
Mailing Address - Street 2:
Mailing Address - City:ARKANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:67005-4011
Mailing Address - Country:US
Mailing Address - Phone:620-442-2100
Mailing Address - Fax:620-442-8945
Practice Address - Street 1:510 W RADIO LN
Practice Address - Street 2:
Practice Address - City:ARKANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:67005-4011
Practice Address - Country:US
Practice Address - Phone:620-442-2100
Practice Address - Fax:620-442-8945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS178913Medicare ID - Type Unspecified