Healthcare Provider Details

I. General information

NPI: 1679560932
Provider Name (Legal Business Name): THE LEGACY AT PARK VIEW
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2005
Last Update Date: 10/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 E SAN JACINTO AVE
ULYSSES KS
67880-2241
US

IV. Provider business mailing address

510 E SAN JACINTO AVE
ULYSSES KS
67880-2241
US

V. Phone/Fax

Practice location:
  • Phone: 620-356-3331
  • Fax: 620-356-1932
Mailing address:
  • Phone: 620-356-3331
  • Fax: 620-356-1932

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License NumberN034001
License Number StateKS

VIII. Authorized Official

Name: KIMBERLE B DOTY
Title or Position: ADMINISTRATOR
Credential:
Phone: 620-356-3331