=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154136612
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEART OF KANSAS FAMILY HEALTH CARE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/11/2025
-----------------------------------------------------
Last Update Date | 02/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1910 18TH ST
-----------------------------------------------------
City | GREAT BEND
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67530-2500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 620-792-5700
-----------------------------------------------------
Fax | 620-792-5742
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1905 19TH ST
-----------------------------------------------------
City | GREAT BEND
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67530-2502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 620-792-5700
-----------------------------------------------------
Fax | 620-792-5742
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | FREDDY GUNN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 620-792-5700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QF0400X
-----------------------------------------------------
Taxonomy Name | Federally Qualified Health Center (FQHC)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------