Provider Demographics
NPI:1215963921
Name:CENTERWELL CERTIFIED HEALTHCARE CORP.
Entity type:Organization
Organization Name:CENTERWELL CERTIFIED HEALTHCARE CORP.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:W
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-434-3030
Mailing Address - Street 1:6330 SPRINT PKWY STE 300
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66211-1157
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12125 WOODCREST EXECUTIVE DR STE 340
Practice Address - Street 2:
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-5004
Practice Address - Country:US
Practice Address - Phone:314-434-3030
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-24
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO586992703Medicaid
MO0000377Medicaid
MO281711002Medicaid
MO261711006Medicaid
MO261711006Medicaid
MO586992703Medicaid
267290AMedicare Oscar/Certification
0003302145OtherMO-COMMERCIAL NUMBER
19153OtherMO-COMMERCIAL NUMBER
013100POtherMO-COMMERCIAL NUMBER
1016876OtherMO-COMMERCIAL NUMBER
112135OtherMO-COMMERCIAL NUMBER
MO281711002Medicaid
267290OtherMO-COMMERCIAL NUMBER
MO0000377Medicaid
=========310OtherMO-CHAMPUS
111019OtherMO-COMMERCIAL NUMBER
2185361OtherMO-COMMERCIAL NUMBER
235394OtherMO-COMMERCIAL NUMBER
MO261711006Medicaid