Healthcare Provider Details

I. General information

NPI: 1790180180
Provider Name (Legal Business Name): ST ROSE HEALTH CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2014
Last Update Date: 02/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3515 BROADWAY AVE
GREAT BEND KS
67530-3633
US

IV. Provider business mailing address

3515 BROADWAY AVE
GREAT BEND KS
67530-3633
US

V. Phone/Fax

Practice location:
  • Phone: 620-792-3345
  • Fax: 620-786-6262
Mailing address:
  • Phone: 620-792-3345
  • Fax: 620-792-6262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHN B MOORE
Title or Position: EXEC DIRECTOR PHYSICIAN PRACTICE
Credential:
Phone: 785-623-2185