Healthcare Provider Details

I. General information

NPI: 1225246317
Provider Name (Legal Business Name): SULLIVAN GANG CARE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2007
Last Update Date: 06/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6719 W. DOUGLAS CIRCLE
WICHITA KS
67209
US

IV. Provider business mailing address

6404 E. PEPPERWOOD CT.
WICHITA KS
67226
US

V. Phone/Fax

Practice location:
  • Phone: 316-838-4862
  • Fax: 316-262-2970
Mailing address:
  • Phone: 316-838-4862
  • Fax: 316-262-2970

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number100417670A
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number100417670A
License Number StateKS

VIII. Authorized Official

Name: MR. GREGORY D. SULLIVAN
Title or Position: OWNER
Credential:
Phone: 316-516-6242