Healthcare Provider Details

I. General information

NPI: 1316961097
Provider Name (Legal Business Name): HEALTHCARE OF WITCHITA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 08/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5005 E 21ST ST N
WICHITA KS
67208-1604
US

IV. Provider business mailing address

5005 E 21ST ST N
WICHITA KS
67208-1604
US

V. Phone/Fax

Practice location:
  • Phone: 316-685-9291
  • Fax: 316-685-2099
Mailing address:
  • Phone: 316-685-9291
  • Fax: 316-685-2099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberN087018
License Number StateKS

VIII. Authorized Official

Name: THOMAS D JOHNSON
Title or Position: PRESIDENT
Credential:
Phone: 316-685-9291