Provider Demographics
NPI:1710923842
Name:NORTHEAST KANSAS CENTER FOR HEALTH AND WELLNESS, INC.
Entity Type:Organization
Organization Name:NORTHEAST KANSAS CENTER FOR HEALTH AND WELLNESS, INC.
Other - Org Name:ESTHER BECKER CENTER FOR HEALTH AND WELLNESS
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:A
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:785-486-2642
Mailing Address - Street 1:240 W 18TH ST
Mailing Address - Street 2:
Mailing Address - City:HORTON
Mailing Address - State:KS
Mailing Address - Zip Code:66439-1245
Mailing Address - Country:US
Mailing Address - Phone:785-486-2642
Mailing Address - Fax:785-486-2842
Practice Address - Street 1:517 MAIN ST
Practice Address - Street 2:
Practice Address - City:EVEREST
Practice Address - State:KS
Practice Address - Zip Code:66424
Practice Address - Country:US
Practice Address - Phone:785-548-7610
Practice Address - Fax:785-486-2842
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSH-007-002207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS110054OtherBLUE SHIELD
KS105444OtherBLUE SHIELD
KS426715OtherBLUE SHIELD
KS928432OtherFIRST GUARD HEALTH PLAN
KS426979OtherBLUE SHIELD
KS426995OtherBLUE SHIELD
KS664990OtherFIRST GUARD HEALTH PLAN
KS110054OtherBLUE SHIELD
KSS70212Medicare UPIN
KS928432OtherFIRST GUARD HEALTH PLAN
KS173490Medicare ID - Type Unspecified
KSI52064Medicare UPIN