Provider Demographics
NPI:1518993377
Name:NORTHEAST KANSAS CENTER FOR HEALTH AND WELLNESS, INC.
Entity Type:Organization
Organization Name:NORTHEAST KANSAS CENTER FOR HEALTH AND WELLNESS, INC.
Other - Org Name:HORTON RURAL HEALTH CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:A
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:785-486-2642
Mailing Address - Street 1:240 W 18TH ST
Mailing Address - Street 2:
Mailing Address - City:HORTON
Mailing Address - State:KS
Mailing Address - Zip Code:66439-1245
Mailing Address - Country:US
Mailing Address - Phone:785-486-2642
Mailing Address - Fax:785-486-2842
Practice Address - Street 1:1903 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:HORTON
Practice Address - State:KS
Practice Address - Zip Code:66439-1238
Practice Address - Country:US
Practice Address - Phone:785-486-2998
Practice Address - Fax:785-486-2736
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSH-007-002207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS110054OtherBLUE SHIELD
KS664990OtherFIRST GUARD HEALTH PLAN
KS105444OtherBLUE SHIELD
KS426979OtherBLUE SHIELD
KS426995OtherBLUE SHIELD
KS928432OtherFIRST GUARD HEALTH PLAN
KS426715OtherBLUE SHIELD
KS928432OtherFIRST GUARD HEALTH PLAN
KS426715OtherBLUE SHIELD
KSS55198Medicare UPIN
KS426995OtherBLUE SHIELD
KS110054OtherBLUE SHIELD