Healthcare Provider Details

I. General information

NPI: 1669967436
Provider Name (Legal Business Name): MEDICALODGES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2018
Last Update Date: 12/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 CHERRY LN
GREAT BEND KS
67530-3152
US

IV. Provider business mailing address

PO BOX 509
COFFEYVILLE KS
67337-0509
US

V. Phone/Fax

Practice location:
  • Phone: 620-792-2165
  • Fax:
Mailing address:
  • Phone: 620-251-6700
  • Fax:

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: CFO
Credential:
Phone: 620-709-0305