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2750 S Roosevelt St Wichita KS 67210-1304 | |
| (316) 652-0152 | |
| (316) 652-0928 |
| Full Name | |
|---|---|
| Speciality | Clinic/Center |
| Location | 2750 S Roosevelt St, Wichita, Kansas |
| Authorized Official Name and Position | Ronald Saal (CFO) |
| Authorized Official Contact | 3162622415 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
2318 E Central Ave Wichita KS 67214-4436 Ph: (316) 262-2415 | 2750 S Roosevelt St Wichita KS 67210-1304 Ph: (316) 652-0152 |
| NPI Number | 1053487579 |
|---|---|
| Provider Enumeration Date | 11/27/2006 |
| Last Update Date | 03/08/2022 |
| Medicare PECOS PAC ID | 5193632941 |
|---|---|
| Medicare Enrollment ID | O20081008000552 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1053487579 | NPI | - | NPPES |
| 003947 | Other | KS | BCBS GROUP |
| 100212200C | Medicaid | KS |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QF0400X | Clinic/center - Federally Qualified Health Center (fqhc) | (Kansas) | Primary |
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