Healthcare Provider Details

I. General information

NPI: 1891605580
Provider Name (Legal Business Name): SAMANTHA MADERA
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2026
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

506 AVENUE L
DODGE CITY KS
67801-5319
US

IV. Provider business mailing address

PO BOX 1905
GARDEN CITY KS
67846-1905
US

V. Phone/Fax

Practice location:
  • Phone: 620-227-8566
  • Fax:
Mailing address:
  • Phone: 620-275-0644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number14983-T
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: