Provider Demographics
NPI:1801893334
Name:WICHITA HOME HEALTH SERVICE, INC.
Entity type:Organization
Organization Name:WICHITA HOME HEALTH SERVICE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CHRYSTAL
Authorized Official - Middle Name:S
Authorized Official - Last Name:EVERETT
Authorized Official - Suffix:
Authorized Official - Credentials:BSHCA
Authorized Official - Phone:940-322-7113
Mailing Address - Street 1:4245 KEMP BLVD STE 420
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76308-2833
Mailing Address - Country:US
Mailing Address - Phone:940-322-7113
Mailing Address - Fax:940-766-6025
Practice Address - Street 1:4245 KEMP BLVD STE 420
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76308-2833
Practice Address - Country:US
Practice Address - Phone:940-322-7113
Practice Address - Fax:940-766-6025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-30
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX001943251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001943OtherSTATE LICENSE NUMBER
TX023500401Medicaid
TX45-7047OtherMEDICARE PROVIDER 45-7047
TX023500401Medicaid