Provider Demographics
NPI:1538647755
Name:CHENNELL FAMILY WELLNESS, LLC
Entity Type:Organization
Organization Name:CHENNELL FAMILY WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHENNELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:620-480-9597
Mailing Address - Street 1:1101 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MCPHERSON
Mailing Address - State:KS
Mailing Address - Zip Code:67460-2845
Mailing Address - Country:US
Mailing Address - Phone:620-504-5996
Mailing Address - Fax:888-263-5552
Practice Address - Street 1:1101 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MCPHERSON
Practice Address - State:KS
Practice Address - Zip Code:67460-2845
Practice Address - Country:US
Practice Address - Phone:620-504-5996
Practice Address - Fax:888-263-5552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-31
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-36397207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS04-36397OtherSTATE LICENSE
KS201207900AMedicaid