Provider Demographics
NPI:1609652072
Name:PRIME HEALTHCARE SERVICES - SAINT JOHN LEAVENWORTH, LLC
Entity type:Organization
Organization Name:PRIME HEALTHCARE SERVICES - SAINT JOHN LEAVENWORTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING ASSOCIATE GENERAL COUNSEL
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:DOAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-235-4307
Mailing Address - Street 1:15604 PINEHURST DR STE 2
Mailing Address - Street 2:
Mailing Address - City:BASEHOR
Mailing Address - State:KS
Mailing Address - Zip Code:66007-8234
Mailing Address - Country:US
Mailing Address - Phone:913-728-2200
Mailing Address - Fax:
Practice Address - Street 1:15604 PINEHURST DR STE 2
Practice Address - Street 2:
Practice Address - City:BASEHOR
Practice Address - State:KS
Practice Address - Zip Code:66007-8234
Practice Address - Country:US
Practice Address - Phone:913-728-2200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-01
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health