=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821789504
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EXCEL OF WICHITA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/15/2023
-----------------------------------------------------
Last Update Date | 05/15/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7101 E 21ST ST N
-----------------------------------------------------
City | WICHITA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67206-1044
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-684-8018
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2420 KNAPP ST
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11235-1006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-942-3483
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MARK HASTINGS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 718-942-3483
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------