Basic Information
| Provider Information | |||||||||
| NPI: | 1184616955 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVACARE MEDICAL CORP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14801 W 117TH ST | ||||||||
| Address2: | |||||||||
| City: | OLATHE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660629305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9137804700 | ||||||||
| FaxNumber: | 9137804700 | ||||||||
| Practice Location | |||||||||
| Address1: | 1710 SW 10TH AVE | ||||||||
| Address2: | |||||||||
| City: | TOPEKA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 666041334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7852355200 | ||||||||
| FaxNumber: | 7852355204 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2005 | ||||||||
| LastUpdateDate: | 04/12/2012 | ||||||||
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| AuthorizedOfficialLastName: | STEVENS | ||||||||
| AuthorizedOfficialFirstName: | JEREL | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9137804700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ADAVCARE MEDICAL CORP | ||||||||
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| AuthorizedOfficialCredential: | ATS, CRTS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BC3200X | N | Suppliers | Durable Medical Equipment & Medical Supplies | Customized Equipment | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 100441790A | 05 | KS | MEDICAID |