Healthcare Provider Details

I. General information

NPI: 1265487359
Provider Name (Legal Business Name): C&S MEDICAL CLINIC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 02/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 SUMMERLON CIRCLE SUITE A
DODGE CITY KS
67801-2905
US

IV. Provider business mailing address

2200 SUMMERLON CIRCLE SUITE A
DODGE CITY KS
67801-2905
US

V. Phone/Fax

Practice location:
  • Phone: 620-408-9700
  • Fax: 620-408-9701
Mailing address:
  • Phone: 620-408-9700
  • Fax: 620-408-9701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: CHRIS SANDOVAL
Title or Position: OFFICE MANAGER
Credential:
Phone: 620-408-9700