Healthcare Provider Details

I. General information

NPI: 1316225543
Provider Name (Legal Business Name): WICHITA PAIN MANAGEMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2011
Last Update Date: 07/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2260 N RIDGE RD ST. 100
WICHITA KS
67205-1132
US

IV. Provider business mailing address

2260 N RIDGE RD ST. 100
WICHITA KS
67205-1132
US

V. Phone/Fax

Practice location:
  • Phone: 316-722-4776
  • Fax: 316-722-4082
Mailing address:
  • Phone: 316-722-4776
  • Fax: 316-722-4082

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: TODD H ECK
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 316-722-4776