Healthcare Provider Details

I. General information

NPI: 1669679924
Provider Name (Legal Business Name): KANSAS VEIN CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10096 E 13TH ST N SUITE 144
WICHITA KS
67206-2645
US

IV. Provider business mailing address

10333 E 21ST ST N SUITE 401
WICHITA KS
67206-3543
US

V. Phone/Fax

Practice location:
  • Phone: 316-634-6622
  • Fax: 316-630-9461
Mailing address:
  • Phone: 316-636-9580
  • Fax: 316-630-9461

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License Number
License Number State

VIII. Authorized Official

Name: PAUL H. CHEATUM
Title or Position: PRESIDENT
Credential: M.D.
Phone: 316-634-6622