Healthcare Provider Details

I. General information

NPI: 1902209703
Provider Name (Legal Business Name): MEDICALODGES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2014
Last Update Date: 11/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

511 N WESTERN AVE
GIRARD KS
66743-1152
US

IV. Provider business mailing address

201 W 8TH ST P.O. BOX 509
COFFEYVILLE KS
67337-5807
US

V. Phone/Fax

Practice location:
  • Phone: 620-724-8288
  • Fax:
Mailing address:
  • Phone: 620-251-6700
  • Fax: 620-709-0442

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. SCOTT HINES
Title or Position: CHIEF FINANCIAL OFFICER
Credential: CPA
Phone: 620-251-6700