Healthcare Provider Details

I. General information

NPI: 1912316811
Provider Name (Legal Business Name): GREAT PLAINS DIABETES RESEARCH, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2014
Last Update Date: 05/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

834 N SOCORA ST SUITE 4
WICHITA KS
67212
US

IV. Provider business mailing address

834 N SOCORA ST SUITE 4
WICHITA KS
67212-3279
US

V. Phone/Fax

Practice location:
  • Phone: 316-440-2802
  • Fax: 316-440-2809
Mailing address:
  • Phone: 316-440-2802
  • Fax: 316-440-2809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number74249
License Number StateKS

VIII. Authorized Official

Name: MRS. RITA PEDIGO
Title or Position: OFFICE MANAGER
Credential:
Phone: 316-440-2802