Healthcare Provider Details

I. General information

NPI: 1033218565
Provider Name (Legal Business Name): HEALTHCORE CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 08/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2707 EAST 21ST STREET NORTH
WICHITA KS
67214-2249
US

IV. Provider business mailing address

2707 EAST 21ST STREET NORTH
WICHITA KS
67214-2249
US

V. Phone/Fax

Practice location:
  • Phone: 316-691-0249
  • Fax: 316-691-9939
Mailing address:
  • Phone: 316-691-0249
  • Fax: 316-691-9939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number1033218565
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number07000887
License Number StateKS
# 3
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number07000882
License Number StateKS

VIII. Authorized Official

Name: MS. TERESA LOVELADY
Title or Position: CEO
Credential:
Phone: 316-691-0249