Healthcare Provider Details

I. General information

NPI: 1245720168
Provider Name (Legal Business Name): UKHS GREAT BEND, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2018
Last Update Date: 03/11/2020
Certification Date: 03/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

514 CLEVELAND ST
GREAT BEND KS
67530-3562
US

IV. Provider business mailing address

514 CLEVELAND ST
GREAT BEND KS
67530-3562
US

V. Phone/Fax

Practice location:
  • Phone: 620-792-8833
  • Fax:
Mailing address:
  • Phone: 620-792-8833
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JESSE MOCK
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 620-791-6272