=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013978485
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COUNTY OF STANTON
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/28/2006
-----------------------------------------------------
Last Update Date | 02/18/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 114 N MAIN ST
-----------------------------------------------------
City | JOHNSON
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67855-0639
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 620-492-1400
-----------------------------------------------------
Fax | 620-492-1608
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 114 N MAIN ST BOX 639
-----------------------------------------------------
City | JOHNSON
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67855-0639
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 620-492-1400
-----------------------------------------------------
Fax | 620-492-1608
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | CHERYL WILKERSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 620-492-1400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------