MEDICARE: COMMUNITY HOUSE OF WELLNESS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	0428352	KS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	464791	OTHER	KS	CHILDREN'S MERCY HEALTH P
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1891901054
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMUNITY HOUSE OF WELLNESS

Provider Business Mailing Address
First Line	:	1121 QUINDARO BLVD
Second Line	:
City	:	KANSAS CITY
State	:	KS
Zip	:	66104-5331
Country	:	US
Telephone Number	:	913-233-1733
Fax Number	:	913-233-0055

Provider Business Practice Location Address
First Line	:	1121 QUINDARO BLVD
Second Line	:
City	:	KANSAS CITY
State	:	KS
Zip	:	66104-5331
Country	:	US
Telephone Number	:	913-233-1733
Fax Number	:	913-233-0055

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. MARVIN MCINTOSH
Credential	:	MEDICAL DOCTOR
Telephone Number	:	913-233-1733

Provider Enumeration Date	:	05/15/2007
Last Update Date	:	09/29/2010

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Directions to “COMMUNITY HOUSE OF WELLNESS ” Practice Location

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