Provider Demographics
NPI:1609908474
Name:COTTON O'NEIL CLINIC REVOCABLE TRUST
Entity Type:Organization
Organization Name:COTTON O'NEIL CLINIC REVOCABLE TRUST
Other - Org Name:COTTON O'NEIL LAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ENROLLMENT COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:KELSEY
Authorized Official - Middle Name:
Authorized Official - Last Name:KOEHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:785-354-5201
Mailing Address - Street 1:901 SW GARFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66606-1670
Mailing Address - Country:US
Mailing Address - Phone:785-354-9591
Mailing Address - Fax:785-354-4268
Practice Address - Street 1:901 SW GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66606-1670
Practice Address - Country:US
Practice Address - Phone:785-354-9591
Practice Address - Fax:785-354-4268
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100217350TMedicaid
130156OtherMEDICARE PTAN
130156OtherMEDICARE PTAN