Provider Demographics
NPI:1871564534
Name:PRAIRIESTAR HEALTH CENTER, INC
Entity type:Organization
Organization Name:PRAIRIESTAR HEALTH CENTER, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:BRYANT
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:620-663-8484
Mailing Address - Street 1:2700 E 30TH AVE
Mailing Address - Street 2:
Mailing Address - City:HUTCHINSON
Mailing Address - State:KS
Mailing Address - Zip Code:67502-1242
Mailing Address - Country:US
Mailing Address - Phone:620-663-8484
Mailing Address - Fax:620-802-0690
Practice Address - Street 1:2700 E 30TH AVE
Practice Address - Street 2:
Practice Address - City:HUTCHINSON
Practice Address - State:KS
Practice Address - Zip Code:67502
Practice Address - Country:US
Practice Address - Phone:620-663-8484
Practice Address - Fax:620-663-9526
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-31
Last Update Date:2025-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
110056OtherKANSAS BLUE CROSS BS
KS100175060BMedicaid
178926Medicare PIN
110056OtherKANSAS BLUE CROSS BS