Provider Demographics
NPI:1427072933
Name:COMPREHENSIVE NEUROLOGY CLINIC
Entity type:Organization
Organization Name:COMPREHENSIVE NEUROLOGY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:316-609-2600
Mailing Address - Street 1:3223 N WEBB RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67226-8175
Mailing Address - Country:US
Mailing Address - Phone:316-609-3001
Mailing Address - Fax:316-609-3050
Practice Address - Street 1:3223 N WEBB RD
Practice Address - Street 2:SUITE 3
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67226-8175
Practice Address - Country:US
Practice Address - Phone:316-609-3001
Practice Address - Fax:316-609-3050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS=========OtherTIN
KS=========OtherTIN