Healthcare Provider Details

I. General information

NPI: 1710307582
Provider Name (Legal Business Name): SPRING RIVER MENTAL HEALTH AND WELLNESS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2014
Last Update Date: 04/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6524 SE QUAKERVALE RD
RIVERTON KS
66770-4214
US

IV. Provider business mailing address

PO BOX 550
RIVERTON KS
66770-0550
US

V. Phone/Fax

Practice location:
  • Phone: 620-848-2380
  • Fax: 620-848-2381
Mailing address:
  • Phone: 620-848-2380
  • Fax: 620-848-2381

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SCOTT JACKSON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 620-848-2300