Healthcare Provider Details

I. General information

NPI: 1487253050
Provider Name (Legal Business Name): CENTRAL CARE PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2020
Last Update Date: 10/23/2020
Certification Date: 10/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3550 S 4TH ST STE 282
LEAVENWORTH KS
66048-5160
US

IV. Provider business mailing address

2337 E CRAWFORD ST
SALINA KS
67401-3713
US

V. Phone/Fax

Practice location:
  • Phone: 913-318-7821
  • Fax: 833-834-7630
Mailing address:
  • Phone: 785-823-0633
  • Fax: 785-823-0658

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QX0203X
TaxonomyRadiation Oncology Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: STACY CLOYD
Title or Position: PROVIDER ENROLLMENT SPECIALIST
Credential:
Phone: 785-823-0633