Provider Demographics
NPI:1477692051
Name:VIA CHRISTI IMMEDIATE CARE, MOTHER MARY ANNE INC.
Entity type:Organization
Organization Name:VIA CHRISTI IMMEDIATE CARE, MOTHER MARY ANNE INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:MS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:D
Authorized Official - Last Name:BETTIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:316-268-5266
Mailing Address - Street 1:1152 S. CLIFTON
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67218-2913
Mailing Address - Country:US
Mailing Address - Phone:316-689-5121
Mailing Address - Fax:316-689-5122
Practice Address - Street 1:1152 S. CLIFTON
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67218-2913
Practice Address - Country:US
Practice Address - Phone:316-689-5121
Practice Address - Fax:316-689-5122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2010-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200452390AMedicaid
KS200452390AMedicaid