Basic Information
| Provider Information | |||||||||
| NPI: | 1063873354 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCED MENS HEALTH, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 241 N HILLSIDE | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672146627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3167769495 | ||||||||
| FaxNumber: | 3166162095 | ||||||||
| Practice Location | |||||||||
| Address1: | 3460 N RIDGE ROAD #90 | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672051222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166899185 | ||||||||
| FaxNumber: | 3166162095 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2016 | ||||||||
| LastUpdateDate: | 03/14/2016 | ||||||||
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| AuthorizedOfficialLastName: | LYDDANE | ||||||||
| AuthorizedOfficialFirstName: | CLAY | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3167224725 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD, PHD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 0435145 | KS | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 200740730A | 05 | KS | MEDICAID |