Provider Demographics
NPI:1891054474
Name:RACY'S MEDICAL CLINIC
Entity Type:Organization
Organization Name:RACY'S MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:CUNDIFF
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:620-855-4616
Mailing Address - Street 1:107 NORTH MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:CIMARRON
Mailing Address - State:KS
Mailing Address - Zip Code:67835-0646
Mailing Address - Country:US
Mailing Address - Phone:620-855-4616
Mailing Address - Fax:620-855-4613
Practice Address - Street 1:107 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:CIMARRON
Practice Address - State:KS
Practice Address - Zip Code:67835-0646
Practice Address - Country:US
Practice Address - Phone:620-855-4616
Practice Address - Fax:620-855-4613
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-16
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS5344884111261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS161882Medicare UPIN