Healthcare Provider Details

I. General information

NPI: 1013264399
Provider Name (Legal Business Name): LA CAMBRA CO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2012
Last Update Date: 09/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

727 N WACO AVE
WICHITA KS
67203-3951
US

IV. Provider business mailing address

727 N WACO AVE
WICHITA KS
67203-3951
US

V. Phone/Fax

Practice location:
  • Phone: 913-424-7000
  • Fax:
Mailing address:
  • Phone: 913-424-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS1201X
TaxonomySleep Medicine (Family Medicine) Physician
License Number50401
License Number StateKS

VIII. Authorized Official

Name: MARK DOMBO
Title or Position: CEO
Credential:
Phone: 913-424-7000