Healthcare Provider Details

I. General information

NPI: 1679115919
Provider Name (Legal Business Name): HOLISTIC PAIN MANAGEMENT OF KANSAS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2019
Last Update Date: 10/20/2022
Certification Date: 10/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 WESTLOOP PL # 198
MANHATTAN KS
66502-2842
US

IV. Provider business mailing address

3780 N GARFIELD AVE SUITE 101
LOVELAND CO
80538
US

V. Phone/Fax

Practice location:
  • Phone: 307-271-2332
  • Fax:
Mailing address:
  • Phone: 307-250-4953
  • Fax: 833-923-2295

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: RYAN SHEDD
Title or Position: CEO
Credential: CRNA
Phone: 307-271-2332