Healthcare Provider Details

I. General information

NPI: 1558495325
Provider Name (Legal Business Name): CENTER FOR INDEPENDENT LIVING SOUTHWEST KANSAS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 09/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1802 E SPRUCE ST
GARDEN CITY KS
67846-6337
US

IV. Provider business mailing address

1802 E SPRUCE ST PO BOX 2090
GARDEN CITY KS
67846-6337
US

V. Phone/Fax

Practice location:
  • Phone: 620-276-1900
  • Fax: 620-271-0200
Mailing address:
  • Phone: 620-276-1900
  • Fax: 620-271-0200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number
License Number State

VIII. Authorized Official

Name: TROY ALAN HORTON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 620-276-1900