MEDICARE: KANSAS MASONIC HOME, 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	315D00000X	Inpatient Hospice	Z087011	KS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0578	OTHER	KS	BLUE CROSS-BLUE SHIELD

General Provider Information

NPI Number	:	1952516346
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KANSAS MASONIC HOME, INC.

Provider Business Mailing Address
First Line	:	401 S SENECA ST
Second Line	:
City	:	WICHITA
State	:	KS
Zip	:	67213-5541
Country	:	US
Telephone Number	:	316-269-7652
Fax Number	:	316-267-2199

Provider Business Practice Location Address
First Line	:	401 S SENECA ST
Second Line	:
City	:	WICHITA
State	:	KS
Zip	:	67213-5541
Country	:	US
Telephone Number	:	316-269-7652
Fax Number	:	316-267-2199

Authorized Official
Title or Position	:	DIRECTOR OF FINANCE
Name	:	TIM C NIKKEL
Credential	:
Telephone Number	:	316-269-7652

Provider Enumeration Date	:	05/11/2007
Last Update Date	:	08/22/2020

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