Provider Demographics
NPI:1649755570
Name:WICHITA MEDICAL MANAGEMENT, LLC
Entity Type:Organization
Organization Name:WICHITA MEDICAL MANAGEMENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:TRACE
Authorized Official - Last Name:GEORGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:325-701-9270
Mailing Address - Street 1:PO BOX 6807
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79608-6807
Mailing Address - Country:US
Mailing Address - Phone:325-701-9270
Mailing Address - Fax:325-701-9272
Practice Address - Street 1:3701 FAIRWAY BLVD STE 114
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76310-1038
Practice Address - Country:US
Practice Address - Phone:325-701-9270
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-26
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty