Basic Information
| Provider Information | |||||||||
| NPI: | 1609908474 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COTTON O'NEIL CLINIC REVOCABLE TRUST | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | COTTON O'NEIL LAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 901 SW GARFIELD AVE | ||||||||
| Address2: | |||||||||
| City: | TOPEKA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 666061670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7853549591 | ||||||||
| FaxNumber: | 7853544268 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 SW GARFIELD AVE | ||||||||
| Address2: | |||||||||
| City: | TOPEKA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 666061670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7853549591 | ||||||||
| FaxNumber: | 7853544268 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2007 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KOEHN | ||||||||
| AuthorizedOfficialFirstName: | KELSEY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ENROLLMENT COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 7853545201 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 130156 | 01 | MEDICARE PTAN | OTHER | 100217350T | 05 | KS | MEDICAID |