Provider Demographics
NPI:1225246317
Name:SULLIVAN GANG CARE CENTER
Entity Type:Organization
Organization Name:SULLIVAN GANG CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:D
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:316-516-6242
Mailing Address - Street 1:6404 E. PEPPERWOOD CT.
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67226
Mailing Address - Country:US
Mailing Address - Phone:316-838-4862
Mailing Address - Fax:316-262-2970
Practice Address - Street 1:6719 W. DOUGLAS CIRCLE
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67209
Practice Address - Country:US
Practice Address - Phone:316-838-4862
Practice Address - Fax:316-262-2970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-20
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS100417670A251C00000X, 3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251C00000XAgenciesDay Training, Developmentally Disabled ServicesGroup - Multi-Specialty
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100417670AMedicaid