=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174274567
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KANSAS COVID RESPONSE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/17/2022
-----------------------------------------------------
Last Update Date | 01/17/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8335 E KELLOGG DR
-----------------------------------------------------
City | WICHITA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67207-1839
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-771-7315
-----------------------------------------------------
Fax | 316-771-7319
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8335 E KELLOGG DR
-----------------------------------------------------
City | WICHITA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67207-1839
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-771-7315
-----------------------------------------------------
Fax | 316-771-7319
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | CHRISTINE BACCI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 316-771-7315
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------