Provider Demographics
NPI:1568066587
Name:STREET MEDICINE KC
Entity Type:Organization
Organization Name:STREET MEDICINE KC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:EDGAR
Authorized Official - Middle Name:
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:913-653-2897
Mailing Address - Street 1:934 WYANDOTTE ST APT 406
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64105-1644
Mailing Address - Country:US
Mailing Address - Phone:913-653-2897
Mailing Address - Fax:
Practice Address - Street 1:1444 E 8TH ST
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64106-1712
Practice Address - Country:US
Practice Address - Phone:816-434-0581
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No332900000XSuppliersNon-Pharmacy Dispensing Site
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)