=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841007739
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAIN STREET CLINIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2024
-----------------------------------------------------
Last Update Date | 08/27/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 450 MORTON STREET
-----------------------------------------------------
City | ELKHART
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67950
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 620-518-3139
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 986
-----------------------------------------------------
City | ELKHART
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67950-0986
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 620-518-3139
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | HEIDY BRILLHART
-----------------------------------------------------
Credential | APRN
-----------------------------------------------------
Telephone | 806-236-6840
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------