Provider Demographics
NPI:1508203241
Name:COLLEGE PARK ANCILLARY, LLC
Entity Type:Organization
Organization Name:COLLEGE PARK ANCILLARY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:CARLON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-508-4090
Mailing Address - Street 1:11755 W 112TH ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66210-2742
Mailing Address - Country:US
Mailing Address - Phone:913-469-0433
Mailing Address - Fax:
Practice Address - Street 1:10600 MASTIN ST
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66212-5723
Practice Address - Country:US
Practice Address - Phone:913-438-0868
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-03
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical