Provider Demographics
NPI:1275075103
Name:NORTHWEST KANSAS TECH COLLEGE
Entity Type:Organization
Organization Name:NORTHWEST KANSAS TECH COLLEGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEAD ATHLETIC TRAINER
Authorized Official - Prefix:
Authorized Official - First Name:SHELBY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:HEATWOLE
Authorized Official - Suffix:
Authorized Official - Credentials:ATC, LAT
Authorized Official - Phone:620-290-4687
Mailing Address - Street 1:417 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:GOODLAND
Mailing Address - State:KS
Mailing Address - Zip Code:67735
Mailing Address - Country:US
Mailing Address - Phone:785-890-1539
Mailing Address - Fax:
Practice Address - Street 1:1209 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:GOODLAND
Practice Address - State:KS
Practice Address - Zip Code:67735-3441
Practice Address - Country:US
Practice Address - Phone:785-890-1539
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-09
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSXSB886824257305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization