Healthcare Provider Details

I. General information

NPI: 1780914697
Provider Name (Legal Business Name): FAMILY CARE CLINIC OF WESTERN KANSAS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2009
Last Update Date: 12/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W ROSS BLVD
DODGE CITY KS
67801-7221
US

IV. Provider business mailing address

200 W ROSS BLVD
DODGE CITY KS
67801-7221
US

V. Phone/Fax

Practice location:
  • Phone: 620-371-7300
  • Fax: 620-371-7304
Mailing address:
  • Phone: 620-371-7300
  • Fax: 620-371-7304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JAMES W. MOFFITT
Title or Position: PRESIDENT
Credential: M.D.
Phone: 620-371-7300