Provider Demographics
NPI:1912391665
Name:KIDSTLC MEDICAL SERVICS, LLC
Entity Type:Organization
Organization Name:KIDSTLC MEDICAL SERVICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:
Authorized Official - Last Name:DOCKING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:913-324-3636
Mailing Address - Street 1:480 S ROGERS RD
Mailing Address - Street 2:
Mailing Address - City:OLATHE
Mailing Address - State:KS
Mailing Address - Zip Code:66062-1706
Mailing Address - Country:US
Mailing Address - Phone:913-324-3636
Mailing Address - Fax:913-324-3894
Practice Address - Street 1:480 S ROGERS RD
Practice Address - Street 2:
Practice Address - City:OLATHE
Practice Address - State:KS
Practice Address - Zip Code:66062-1706
Practice Address - Country:US
Practice Address - Phone:913-324-3636
Practice Address - Fax:913-324-3894
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KIDSTLC, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-03-20
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)Group - Multi-Specialty