=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497900708
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KANSAS JOINT & SPINE INSTITUTE, CHARTERED
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/01/2008
-----------------------------------------------------
Last Update Date | 12/01/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10100 SHANNON WOODS ST
-----------------------------------------------------
City | WICHITA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67226-4103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-858-1900
-----------------------------------------------------
Fax | 316-858-1905
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10100 SHANNON WOODS ST
-----------------------------------------------------
City | WICHITA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67226-4103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-858-1900
-----------------------------------------------------
Fax | 316-858-1905
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | DAVID SCHLUCK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 316-858-1900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | 11-02260
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------