Provider Demographics
NPI:1598145211
Name:SPORTS MEDICINE AND ORTHOPEDIC CLINIC OF COWLEY CO LLC
Entity Type:Organization
Organization Name:SPORTS MEDICINE AND ORTHOPEDIC CLINIC OF COWLEY CO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/MANAGER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JERYL
Authorized Official - Middle Name:G
Authorized Official - Last Name:FULLEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:620-222-6210
Mailing Address - Street 1:1305 E 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:KS
Mailing Address - Zip Code:67156-2406
Mailing Address - Country:US
Mailing Address - Phone:620-222-6210
Mailing Address - Fax:
Practice Address - Street 1:1305 E 5TH AVE
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:KS
Practice Address - Zip Code:67156-2406
Practice Address - Country:US
Practice Address - Phone:620-222-6210
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-08
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS4-16478261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service