Healthcare Provider Details

I. General information

NPI: 1164503249
Provider Name (Legal Business Name): MEDICALODGES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 07/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

619 S US HIGHWAY 77
DOUGLASS KS
67039-8321
US

IV. Provider business mailing address

619 S US HIGHWAY 77
DOUGLASS KS
67039-8321
US

V. Phone/Fax

Practice location:
  • Phone: 316-747-2157
  • Fax: 316-747-2084
Mailing address:
  • Phone: 316-747-2157
  • Fax: 316-747-2084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberN008001
License Number StateKS

VIII. Authorized Official

Name: MS. CATHY W FISHER
Title or Position: V.P. OF FINANCIAL REPORTING
Credential:
Phone: 620-251-6700