Healthcare Provider Details

I. General information

NPI: 1780192880
Provider Name (Legal Business Name): MR. RICHARD JOE RANGEL III
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2018
Last Update Date: 08/18/2020
Certification Date: 08/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5500 E KELLOGG DR
WICHITA KS
67218-1607
US

IV. Provider business mailing address

5500 E KELLOGG DR
WICHITA KS
67218-1607
US

V. Phone/Fax

Practice location:
  • Phone: 316-685-2221
  • Fax: 316-634-3075
Mailing address:
  • Phone: 316-685-2221
  • Fax: 316-634-3075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number11075
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: