Provider Demographics
NPI:1801058748
Name:KICKAPOO NATION HEALTH CENTER
Entity type:Organization
Organization Name:KICKAPOO NATION HEALTH CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JONNAH
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKINNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:785-915-9751
Mailing Address - Street 1:1117 GOLDFINCH ROAD
Mailing Address - Street 2:
Mailing Address - City:HORTON
Mailing Address - State:KS
Mailing Address - Zip Code:66439
Mailing Address - Country:US
Mailing Address - Phone:785-486-2154
Mailing Address - Fax:785-486-2158
Practice Address - Street 1:1117 GOLDFINCH ROAD
Practice Address - Street 2:
Practice Address - City:HORTON
Practice Address - State:KS
Practice Address - Zip Code:66439
Practice Address - Country:US
Practice Address - Phone:785-486-2154
Practice Address - Fax:785-486-2158
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-01
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200438190AMedicaid
1718052OtherNABP