El Dorado Clinic, P.a.
Organization Active NPI Rural Health Clinic/Center · El Dorado, KS
NPI 1780787176 · NPPES record last updated Feb 7, 2019
Key facts
- NPI
- 1780787176
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Rural Health Clinic/Center 261QR1300X
- Legal business name
- EL DORADO CLINIC, P.A.
- Practice address
- 700 W Central Ave
Ste 205
El Dorado, KS 67042-2184 - Phone
- (316) 321-2010
- Fax
- (316) 321-8871
- NPI assigned
- Sep 7, 2006
- Organization subpart
- No
Authorized official
- Name
- Melissa A Butts
- Title
- Clinic Administrator
- Phone
- (316) 321-8850
Owners & managing parties with NPI records 2
-
Crystal D Faudere, D.O.
-
Diane D Nightengale, M.D.
Other NPIs with the same Medicare PAC ID 1
Practitioners 7
-
Crystal D Faudere, D.O.
-
Russell R McCaig, P.A.
-
Diane D Nightengale, M.D.
-
Sondra Kay Ferguson, APRN
-
Alexa Paige McGraw, ARNP
-
Lauren B Ferrell, M.D.
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in KS
Rural health clinic certification: CCN 178925
- Legal name
- EL DORADO CLINIC, P.A.
- Certification status
- Active
- Provider type (POS)
- Rural health clinic
- Participating since
- Dec 28, 1995
- Last certification
- May 31, 2017
- Ownership / control type
- 1B
- Organization structure
- Corporation · Proprietary
- Incorporated
- Dec 22, 1970 in KS
- Enrollment address
- 700W Central
Suite 205
El Dorado, KS 67042-2186
All disclosed owners & managing parties 3
| Name | Role | Since | Share |
|---|---|---|---|
| Shelley Weaver |
Contracted Managing Employee |
Nov 27, 2023 | |
| W-2 Managing Employee |
Nov 27, 2023 | ||
| Crystal D Faudere |
5% Or Greater Direct Ownership Interest | Jan 1, 2010 | 50% |
| Corporate Officer |
Jan 1, 2010 | ||
| Diane D Nightengale |
5% Or Greater Direct Ownership Interest |
Jul 1, 1990 | 50% |
| Corporate Officer |
Jul 1, 1990 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20101122001353 | KS | Part a Provider - Rural Health Clinic | 7911944897 | Practice locations: El Dorado, KS |
National Provider Directory
Locations
700 W Central Ave
Ste 205
El Dorado, KS 67042
Phone (316) 321-2010
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician |
207Q00000X | |||
| Rural Health Clinic/Center | 261QR1300X | Yes |
Addresses
Primary practice location
700 W Central Ave
Ste 205
El Dorado, KS 67042-2184
Mailing address
700 W Central Ave
Ste 205
El Dorado, KS 67042-2184
Phone (316) 321-2010
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 100213650B | Medicaid | KS | |
| 001172 | Other | KS | BCBSKS RHC NUMBER |
Other names
- El Dorado Clinic, P.A., RHC
Other providers in El Dorado, KS
- Bradley David Eck
- Todd Henry Eck
- El Dorado Care and Rehabilitation Center, LLC
- El Dorado Chiropractic PA
- El Dorado Clinic, P.a.
- El Dorado Family Dentistry
- El Dorado Family Dentistry P.a.
- El Dorado Operator, LLC
- El Dorado Pharmacy Inc
- El Dorado Pharmacy Inc
All providers in El Dorado, KS · Rural Health Clinic/Center in Kansas
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Feb 7, 2019. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.