Healthcare Provider Details

I. General information

NPI: 1164908281
Provider Name (Legal Business Name): WICHITA PRIMARY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2018
Last Update Date: 01/25/2021
Certification Date: 01/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2230 N RIDGE RD
WICHITA KS
67205-1053
US

IV. Provider business mailing address

2230 N RIDGE RD
WICHITA KS
67205-1053
US

V. Phone/Fax

Practice location:
  • Phone: 316-448-8339
  • Fax: 316-221-7149
Mailing address:
  • Phone: 316-448-8339
  • Fax: 316-221-7149

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: HEIDI LARISON
Title or Position: OWNER
Credential: MD
Phone: 316-448-8339