=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548842354
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE BAOBAB TREE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/22/2021
-----------------------------------------------------
Last Update Date | 04/22/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4707 NEBRASKA AVE
-----------------------------------------------------
City | KANSAS CITY
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66102-1735
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-791-7239
-----------------------------------------------------
Fax | 816-791-7165
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5824 E 40TH TER
-----------------------------------------------------
City | KANSAS CITY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64129-1714
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-895-2742
-----------------------------------------------------
Fax | 816-791-7165
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | KIMBERLY LARTEY
-----------------------------------------------------
Credential | CPM
-----------------------------------------------------
Telephone | 816-791-7239
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QC1500X
-----------------------------------------------------
Taxonomy Name | Community Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------