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21624 Midland Dr Shawnee KS 66218-9064 | |
| (913) 643-0075 | |
| (913) 643-0077 |
| Full Name | |
|---|---|
| Speciality | Clinic/center - Multi-specialty |
| Location | 21624 Midland Dr, Shawnee, Kansas |
| Authorized Official Name and Position | Tracy A Clark (PRACTICE ADMINISTRATOR) |
| Authorized Official Contact | 9136430075 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
21624 Midland Dr Shawnee KS 66218-9064 Ph: (913) 643-0075 | 21624 Midland Dr Shawnee KS 66218-9064 Ph: (913) 643-0075 |
| NPI Number | 1336417831 |
|---|---|
| Provider Enumeration Date | 12/12/2011 |
| Last Update Date | 12/13/2011 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1336417831 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QM1300X | Clinic/center - Multi-specialty | 04-23518 (Kansas) | Primary |
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