Healthcare Provider Details

I. General information

NPI: 1578907879
Provider Name (Legal Business Name): USP LEAVENWORTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2013
Last Update Date: 04/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 METROPOLITAN AVE
LEAVENWORTH KS
66048-1254
US

IV. Provider business mailing address

1300 METROPOLITAN AVE
LEAVENWORTH KS
66048-1254
US

V. Phone/Fax

Practice location:
  • Phone: 913-682-8700
  • Fax:
Mailing address:
  • Phone: 913-682-8700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JUSTIN BLEVINS
Title or Position: HEALTH SERVICES ADMINISTRATOR
Credential:
Phone: 913-682-8700