Provider Demographics
NPI:1881838134
Name:KANSAS CITY COMMUNITY CENTER
Entity Type:Organization
Organization Name:KANSAS CITY COMMUNITY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:MYRNA
Authorized Official - Middle Name:
Authorized Official - Last Name:TRICKEY
Authorized Official - Suffix:
Authorized Official - Credentials:MPA
Authorized Official - Phone:816-421-6670
Mailing Address - Street 1:1730 PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64127-2544
Mailing Address - Country:US
Mailing Address - Phone:816-421-6670
Mailing Address - Fax:816-421-4701
Practice Address - Street 1:1534 CAMPBELL ST
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64108-1520
Practice Address - Country:US
Practice Address - Phone:815-842-1805
Practice Address - Fax:816-214-9579
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-29
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO866471501Medicaid