MEDICARE: KENWOOD PLAZA, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility	N093004	KS

General Provider Information

NPI Number	:	1306823406
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KENWOOD PLAZA, INC.

Provider Business Mailing Address
First Line	:	607 E 1ST AVE
Second Line	:
City	:	ST JOHN
State	:	KS
Zip	:	67576-2223
Country	:	US
Telephone Number	:	620-549-6133
Fax Number	:	620-549-9971

Provider Business Practice Location Address
First Line	:	607 E 1ST AVE
Second Line	:
City	:	ST JOHN
State	:	KS
Zip	:	67576-2223
Country	:	US
Telephone Number	:	620-549-6133
Fax Number	:	620-549-9971

Authorized Official
Title or Position	:	CHIEF FINANCIAL OFFICER
Name	:	TRACY L BARTLEY
Credential	:
Telephone Number	:	785-273-3383

Provider Enumeration Date	:	12/29/2005
Last Update Date	:	08/22/2020

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Directions to “KENWOOD PLAZA, INC. ” Practice Location

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