Provider Demographics
NPI:1831848316
Name:GROW HEALTHCARE GROUP OF KANSAS PA
Entity type:Organization
Organization Name:GROW HEALTHCARE GROUP OF KANSAS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JAKE
Authorized Official - Middle Name:
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:347-851-1139
Mailing Address - Street 1:801 E DOUGLAS AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67202-3548
Mailing Address - Country:US
Mailing Address - Phone:316-974-3161
Mailing Address - Fax:
Practice Address - Street 1:801 E DOUGLAS AVE FL 2
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67202-3548
Practice Address - Country:US
Practice Address - Phone:316-974-3161
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-22
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health