Basic Information
| Provider Information | |||||||||
| NPI: | 1255856258 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HEART OF KANSAS FAMILY HEALTH CARE, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | STAFFORD CLINIC SITE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1905 19TH ST | ||||||||
| Address2: | |||||||||
| City: | GREAT BEND | ||||||||
| State: | KS | ||||||||
| PostalCode: | 675302502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6207925700 | ||||||||
| FaxNumber: | 6207925742 | ||||||||
| Practice Location | |||||||||
| Address1: | 412 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | STAFFORD | ||||||||
| State: | KS | ||||||||
| PostalCode: | 675782010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6207925700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2017 | ||||||||
| LastUpdateDate: | 11/08/2017 | ||||||||
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| AuthorizedOfficialLastName: | NOKES | ||||||||
| AuthorizedOfficialFirstName: | JYL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CO | ||||||||
| AuthorizedOfficialTelephone: | 6207925700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HEART OF KANSAS FAMILY HEALTH CARE, INC. | ||||||||
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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.