Provider Demographics
NPI:1164908281
Name:WICHITA PRIMARY CARE LLC
Entity Type:Organization
Organization Name:WICHITA PRIMARY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HEIDI
Authorized Official - Middle Name:
Authorized Official - Last Name:LARISON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:316-448-8339
Mailing Address - Street 1:2230 N RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67205-1053
Mailing Address - Country:US
Mailing Address - Phone:316-448-8339
Mailing Address - Fax:316-221-7149
Practice Address - Street 1:2230 N RIDGE RD
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67205-1053
Practice Address - Country:US
Practice Address - Phone:316-448-8339
Practice Address - Fax:316-221-7149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-11
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Single Specialty