Healthcare Provider Details

I. General information

NPI: 1396301867
Provider Name (Legal Business Name): UKHS GREAT BEND LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2019
Last Update Date: 05/10/2019
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: 620-786-6163
  • Fax:
Mailing address:
  • Phone: 620-786-6117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JESSE MOCK
Title or Position: CEO
Credential:
Phone: 785-656-9434