Healthcare Provider Details

I. General information

NPI: 1780787176
Provider Name (Legal Business Name): EL DORADO CLINIC, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 02/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 W CENTRAL AVE STE 205
EL DORADO KS
67042-2184
US

IV. Provider business mailing address

700 W CENTRAL AVE STE 205
EL DORADO KS
67042-2184
US

V. Phone/Fax

Practice location:
  • Phone: 316-321-2010
  • Fax: 316-321-8871
Mailing address:
  • Phone: 316-321-2010
  • Fax: 316-321-8871

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MELISSA A BUTTS
Title or Position: CLINIC ADMINISTRATOR
Credential:
Phone: 316-321-8850