Provider Demographics
NPI:1770559767
Name:EL DORADO CLINIC, P.A.
Entity type:Organization
Organization Name:EL DORADO CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CHERRIE
Authorized Official - Middle Name:T
Authorized Official - Last Name:KEHLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:316-321-8850
Mailing Address - Street 1:700 W CENTRAL AVE
Mailing Address - Street 2:STE 205
Mailing Address - City:EL DORADO
Mailing Address - State:KS
Mailing Address - Zip Code:67042-2184
Mailing Address - Country:US
Mailing Address - Phone:316-321-2010
Mailing Address - Fax:316-321-8871
Practice Address - Street 1:700 W CENTRAL AVE
Practice Address - Street 2:STE 205
Practice Address - City:EL DORADO
Practice Address - State:KS
Practice Address - Zip Code:67042-2184
Practice Address - Country:US
Practice Address - Phone:316-321-2010
Practice Address - Fax:316-321-8871
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-28
Last Update Date:2010-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100213650AMedicaid
KS100213650BMedicaid
KS100213650AMedicaid