Basic Information
| Provider Information | |||||||||
| NPI: | 1104880947 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WEST CENTRAL KANSAS ASSOCIATION, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | RUSSELL REGIONAL HOSPITAL AMBULANCE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | RUSSELL | ||||||||
| State: | KS | ||||||||
| PostalCode: | 676652920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7854833131 | ||||||||
| FaxNumber: | 7854834859 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | RUSSELL | ||||||||
| State: | KS | ||||||||
| PostalCode: | 676652920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7854833131 | ||||||||
| FaxNumber: | 7854834859 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2006 | ||||||||
| LastUpdateDate: | 08/16/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BODEN | ||||||||
| AuthorizedOfficialFirstName: | SHELLEY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7854833131 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X | H084001 | KS | Y | Transportation Services | Ambulance |
ID Information
| ID | Type | State | Issuer | Description | 100104400B | 05 | KS | MEDICAID | 100306710F | 05 | KS | MEDICAID | 112005 | 01 | KS | BLUE SHIELD | OTHER |