Healthcare Provider Details

I. General information

NPI: 1851936124
Provider Name (Legal Business Name): CLEARWATER AL OPCO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2019
Last Update Date: 11/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 N 4TH ST
CLEARWATER KS
67026-9708
US

IV. Provider business mailing address

440 N 4TH ST
CLEARWATER KS
67026-9708
US

V. Phone/Fax

Practice location:
  • Phone: 620-584-4257
  • Fax: 620-584-4575
Mailing address:
  • Phone: 620-584-4257
  • Fax: 620-584-4575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. WILLIAM MATTHEW NOVOTNY
Title or Position: CEO
Credential:
Phone: 785-789-4750