Healthcare Provider Details

I. General information

NPI: 1205802279
Provider Name (Legal Business Name): CRISTO REY HEALTHCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

907A E JESUIT LN
ST MARYS KS
66536-9605
US

IV. Provider business mailing address

907A E JESUIT LN
ST MARYS KS
66536-9605
US

V. Phone/Fax

Practice location:
  • Phone: 785-437-3711
  • Fax: 785-437-6711
Mailing address:
  • Phone: 785-437-3711
  • Fax: 785-437-6711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number04-23089
License Number StateKS

VIII. Authorized Official

Name: DR. CARL BRUCE CARROLL
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 785-437-3711