Healthcare Provider Details

I. General information

NPI: 1417045139
Provider Name (Legal Business Name): MEDICALODGES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

501 ASSEMBLY LN
PAOLA KS
66071-1854
US

IV. Provider business mailing address

501 ASSEMBLY LN
PAOLA KS
66071-1854
US

V. Phone/Fax

Practice location:
  • Phone: 913-294-3345
  • Fax: 913-294-3115
Mailing address:
  • Phone: 913-294-3345
  • Fax: 913-294-3115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberN061002
License Number StateKS

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier100109750A
Identifier TypeMEDICAID
Identifier StateKS
Identifier Issuer

VIII. Authorized Official

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