Basic Information
| Provider Information | |||||||||
| NPI: | 1033218565 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HEALTHCORE CLINIC INC | ||||||||
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| OtherOrganizationName: | CENTER FOR HEALTH AND WELLNESS | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2707 EAST 21ST STREET NORTH | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672142249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166910249 | ||||||||
| FaxNumber: | 3166919939 | ||||||||
| Practice Location | |||||||||
| Address1: | 2707 EAST 21ST STREET NORTH | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672142249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166910249 | ||||||||
| FaxNumber: | 3166919939 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2006 | ||||||||
| LastUpdateDate: | 08/14/2015 | ||||||||
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| AuthorizedOfficialLastName: | LOVELADY | ||||||||
| AuthorizedOfficialFirstName: | TERESA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3166910249 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | 07000882 | KS | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 261QM0801X | 07000887 | KS | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QF0400X | 1033218565 | KS | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 100321990 | 05 | KS | MEDICAID | 100321990C | 05 | KS | MEDICAID | 100321990A | 05 | KS | MEDICAID |