Healthcare Provider Details

I. General information

NPI: 1639624364
Provider Name (Legal Business Name): PRIME HEALTHCARE SERVICES-PROVIDENCE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2016
Last Update Date: 08/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8929 PARALLEL PKWY
KANSAS CITY KS
66112-1689
US

IV. Provider business mailing address

8929 PARALLEL PKWY
KANSAS CITY KS
66112-1689
US

V. Phone/Fax

Practice location:
  • Phone: 913-596-3229
  • Fax:
Mailing address:
  • Phone: 913-596-3229
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberN105013
License Number StateKS

VIII. Authorized Official

Name: CHRISTOPHER DOAN
Title or Position: CHIEF COMPLIANCE COUNSEL
Credential:
Phone: 909-235-4307