Healthcare Provider Details

I. General information

NPI: 1467549378
Provider Name (Legal Business Name): MEDICALODGES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 10/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1637 RILEY ST
ATCHISON KS
66002-1514
US

IV. Provider business mailing address

1637 RILEY ST
ATCHISON KS
66002-1514
US

V. Phone/Fax

Practice location:
  • Phone: 913-367-6066
  • Fax: 913-367-4327
Mailing address:
  • Phone: 913-367-6066
  • Fax: 913-367-4327

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberN003002
License Number StateKS

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier100107560A
Identifier TypeMEDICAID
Identifier StateKS
Identifier Issuer

VIII. Authorized Official

Name: MR. SCOTT L HINES
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 620-709-0305