Healthcare Provider Details

I. General information

NPI: 1346869088
Provider Name (Legal Business Name): CENTRAL CARE, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2020
Last Update Date: 04/13/2020
Certification Date: 04/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 W 15TH ST STE 203
LIBERAL KS
67901-2455
US

IV. Provider business mailing address

2337 E CRAWFORD ST
SALINA KS
67401-3713
US

V. Phone/Fax

Practice location:
  • Phone: 620-624-4700
  • Fax: 888-235-3625
Mailing address:
  • Phone: 785-823-0633
  • Fax: 844-854-4662

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State

VIII. Authorized Official

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