Healthcare Provider Details

I. General information

NPI: 1639094477
Provider Name (Legal Business Name): BWE KU SOE I
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2026
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4130 N KANSAS AVE
KANSAS CITY MO
64117-1641
US

IV. Provider business mailing address

4130 N KANSAS AVE
KANSAS CITY MO
64117-1641
US

V. Phone/Fax

Practice location:
  • Phone: 816-699-7269
  • Fax:
Mailing address:
  • Phone: 816-699-7269
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171R00000X
TaxonomyInterpreter
License Number$$$$$$$$$
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: