Provider Demographics
NPI:1831310119
Name:ELEVEN-TWELVE COMPANY
Entity Type:Organization
Organization Name:ELEVEN-TWELVE COMPANY
Other - Org Name:KANSAS CARDIAC CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:ALVAREZ
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:316-267-0159
Mailing Address - Street 1:1144 N SAINT FRANCIS ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67214-2814
Mailing Address - Country:US
Mailing Address - Phone:316-267-0159
Mailing Address - Fax:316-267-3601
Practice Address - Street 1:1144 N SAINT FRANCIS ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-2814
Practice Address - Country:US
Practice Address - Phone:316-267-0159
Practice Address - Fax:316-267-3601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-23137207R00000X
207RC0000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100083020AMedicaid
KS100158960BMedicaid
KS100197170AMedicaid
KS100236410CMedicaid
1366520686OtherNPI
1073595815OtherNPI
KS100402610CMedicaid
1710969548OtherNPI
1588646236OtherNPI
1811979644OtherNPI
F74219Medicare UPIN
KS100197170AMedicaid
B68206Medicare UPIN
KS100158960BMedicaid
1811979644OtherNPI
KS100402610CMedicaid
P38774Medicare UPIN
045261Medicare ID - Type Unspecified
041878Medicare ID - Type Unspecified
KS100236410CMedicaid