Provider Demographics
NPI:1386739035
Name:PRIMARY CARE CENTER OF KANSAS CITY LLC
Entity type:Organization
Organization Name:PRIMARY CARE CENTER OF KANSAS CITY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAN
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:816-795-6000
Mailing Address - Street 1:PO BOX 480497
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64148
Mailing Address - Country:US
Mailing Address - Phone:816-795-6000
Mailing Address - Fax:816-795-6064
Practice Address - Street 1:4741 S ARROWHEAD
Practice Address - Street 2:SUITE B
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64055
Practice Address - Country:US
Practice Address - Phone:816-795-6000
Practice Address - Fax:816-795-6064
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOD0101786261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO248700718Medicaid
MON559766Medicare ID - Type Unspecified
MO248700718Medicaid