Provider Demographics
NPI:1477634301
Name:COUNTY OF WALLACE
Entity type:Organization
Organization Name:COUNTY OF WALLACE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADM/RN
Authorized Official - Prefix:
Authorized Official - First Name:TONYA
Authorized Official - Middle Name:
Authorized Official - Last Name:MEDINA
Authorized Official - Suffix:
Authorized Official - Credentials:ADMINISTRATOR
Authorized Official - Phone:785-852-4272
Mailing Address - Street 1:313 MAIN ST.
Mailing Address - Street 2:
Mailing Address - City:SHARON SPRINGS
Mailing Address - State:KS
Mailing Address - Zip Code:67758
Mailing Address - Country:US
Mailing Address - Phone:785-852-4272
Mailing Address - Fax:785-852-4249
Practice Address - Street 1:104 E 4TH
Practice Address - Street 2:
Practice Address - City:SHARON SPRINGS
Practice Address - State:KS
Practice Address - Zip Code:67758-9715
Practice Address - Country:US
Practice Address - Phone:785-852-4272
Practice Address - Fax:785-852-4249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2024-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0523662163WC1500X
261QP0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
No163WC1500XNursing Service ProvidersRegistered NurseCommunity HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100091770AMedicaid
KS1477634301OtherBCBS
KS1477634301Medicaid