Provider Demographics
NPI:1063873354
Name:ADVANCED MENS HEALTH, LLC
Entity type:Organization
Organization Name:ADVANCED MENS HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CLAY
Authorized Official - Middle Name:E
Authorized Official - Last Name:LYDDANE
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:316-722-4725
Mailing Address - Street 1:241 N HILLSIDE
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67214-6627
Mailing Address - Country:US
Mailing Address - Phone:316-776-9495
Mailing Address - Fax:316-616-2095
Practice Address - Street 1:3460 N RIDGE ROAD #90
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67205-1222
Practice Address - Country:US
Practice Address - Phone:316-689-9185
Practice Address - Fax:316-616-2095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-14
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0435145174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200740730AMedicaid
KS200740730AMedicaid