Basic Information
| Provider Information | |||||||||
| NPI: | 1083271431 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KANSAS CITY CARE CLINIC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | KC CARE HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3515 BROADWAY BLVD | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641112501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8167535144 | ||||||||
| FaxNumber: | 8167530804 | ||||||||
| Practice Location | |||||||||
| Address1: | 1106 E 30TH ST STE B | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641091507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8167535144 | ||||||||
| FaxNumber: | 8167530804 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2019 | ||||||||
| LastUpdateDate: | 11/25/2020 | ||||||||
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| AuthorizedOfficialLastName: | FRANKLIN | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | WILSON | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 8167772763 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | KANSAS CITY CARE CLINIC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 11/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.