Provider Demographics
NPI:1841007739
Name:MAIN STREET CLINIC
Entity type:Organization
Organization Name:MAIN STREET CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRILLHART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:806-382-0941
Mailing Address - Street 1:HC 2 BOX 6B 116 GLEN ROAD
Mailing Address - Street 2:
Mailing Address - City:KEYES
Mailing Address - State:OK
Mailing Address - Zip Code:73947
Mailing Address - Country:US
Mailing Address - Phone:806-236-6840
Mailing Address - Fax:
Practice Address - Street 1:450 MORTON STREET
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:KS
Practice Address - Zip Code:67950
Practice Address - Country:US
Practice Address - Phone:806-236-6840
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-13
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty