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General NPI Number Information
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NPI Number | 1164908281
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Entity Type | Organization
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Legal Business Name | WICHITA PRIMARY CARE LLC
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Dates
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Enumeration Date | 07/11/2018
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Last Update Date | 01/25/2021
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Provider Practice Location Address
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Address Line | 2230 N RIDGE RD
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City | WICHITA
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State | KS
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Zip | 67205-1053
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Country | US
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Telephone | 316-448-8339
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Fax | 316-221-7149
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Provider Business Mailing Address
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Address Line | 2230 N RIDGE RD
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City | WICHITA
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State | KS
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Zip | 67205-1053
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Country | US
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Telephone | 316-448-8339
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Fax | 316-221-7149
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Authorized Official
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Title or Position | OWNER
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Name | HEIDI LARISON
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Credential | MD
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Telephone | 316-448-8339
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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