Provider Demographics
NPI:1336342856
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:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
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 1:240 W 18TH ST
Practice Address - Street 2:
Practice Address - City:HORTON
Practice Address - State:KS
Practice Address - Zip Code:66439-1245
Practice Address - Country:US
Practice Address - Phone:785-486-2642
Practice Address - Fax:785-486-2842
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSH-007-002367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS004631OtherBC-BS OF KS