Provider Demographics
NPI:1407144058
Name:HEALING WATERS WICHITA LC
Entity type:Organization
Organization Name:HEALING WATERS WICHITA LC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:GORECKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:316-262-2995
Mailing Address - Street 1:33 BUFORD VILLAGE WAY
Mailing Address - Street 2:SUITE 325
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30518-8843
Mailing Address - Country:US
Mailing Address - Phone:678-730-7780
Mailing Address - Fax:678-730-7786
Practice Address - Street 1:2000 N ROCK RD
Practice Address - Street 2:SUITE 100
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-1201
Practice Address - Country:US
Practice Address - Phone:316-262-2995
Practice Address - Fax:316-262-2546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-18
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200468790AMedicaid
KS201097690AMedicaid
OK200468790AMedicaid