Healthcare Provider Details

I. General information

NPI: 1417933656
Provider Name (Legal Business Name): HILLTOP LODGE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2005
Last Update Date: 11/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 N. INDEPENDENCE AVE
BELOIT KS
67420-0467
US

IV. Provider business mailing address

P.O. BOX 467
BELOIT KS
67420-0467
US

V. Phone/Fax

Practice location:
  • Phone: 785-738-3516
  • Fax: 785-738-2332
Mailing address:
  • Phone: 785-738-3516
  • Fax: 785-738-2332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberN062001
License Number StateKS

VIII. Authorized Official

Name: MR. BRADLEY JAY HEIDRICK
Title or Position: VICE PRESIDENT
Credential:
Phone: 785-738-3516