Basic Information
Provider Information | |||||||||
NPI: | 1528254463 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | UNITED METHODIST WESTERN KANSAS MEXICAN AMERICAN MINISTRIES,INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | GENESIS FAMILY HEALTH | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 766 | ||||||||
Address2: |   | ||||||||
City: | GARDEN CITY | ||||||||
State: | KS | ||||||||
PostalCode: | 678460766 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6202717400 | ||||||||
FaxNumber: | 6207084463 | ||||||||
Practice Location | |||||||||
Address1: | 1700 AVENUE F | ||||||||
Address2: |   | ||||||||
City: | DODGE CITY | ||||||||
State: | KS | ||||||||
PostalCode: | 678014541 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6202556821 | ||||||||
FaxNumber: | 6202252422 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/24/2007 | ||||||||
LastUpdateDate: | 04/27/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WRIGHT | ||||||||
AuthorizedOfficialFirstName: | JULIE | ||||||||
AuthorizedOfficialMiddleName: | K | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 6202717400 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/27/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X |   |   | N |   | Suppliers | Non-Pharmacy Dispensing Site |   | 261QF0400X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | CH07463F | 01 |   | HRSA OFFICE OF PHARMACY AFFAIRS 340B PROGRAM | OTHER | 100314080F | 05 | KS |   | MEDICAID |