Provider Demographics
NPI:1689699613
Name:DODGE CITY DIAGNOSTIC, LLC
Entity Type:Organization
Organization Name:DODGE CITY DIAGNOSTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JONI
Authorized Official - Middle Name:L
Authorized Official - Last Name:REITER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:620-227-7771
Mailing Address - Street 1:2603 CENTRAL AVENUE
Mailing Address - Street 2:
Mailing Address - City:DODGE CITY
Mailing Address - State:KS
Mailing Address - Zip Code:67801-6200
Mailing Address - Country:US
Mailing Address - Phone:620-227-7771
Mailing Address - Fax:
Practice Address - Street 1:2603 CENTRAL AVENUE
Practice Address - Street 2:
Practice Address - City:DODGE CITY
Practice Address - State:KS
Practice Address - Zip Code:67801-6200
Practice Address - Country:US
Practice Address - Phone:620-227-7771
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100428180AMedicaid
KS1447259221OtherDR. ALEXANDER B. NEEL
KS100428180AMedicaid