=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588848352
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CAH ACQUISITION COMPANY 3 LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/28/2007
-----------------------------------------------------
Last Update Date | 08/02/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 517 MAIN ST
-----------------------------------------------------
City | EVEREST
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66424-9157
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 785-548-7610
-----------------------------------------------------
Fax | 785-486-2842
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1100 MAIN ST SUITE 2350
-----------------------------------------------------
City | KANSAS CITY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64105-2120
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 785-486-2642
-----------------------------------------------------
Fax | 785-486-2842
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | TERRY W NICHOLS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 785-486-2642
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | H-007-002
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------