Healthcare Provider Details

I. General information

NPI: 1629801451
Provider Name (Legal Business Name): MONICA NACOLE ROSEBOROUGH OPERATOR OWNER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2024
Last Update Date: 08/26/2024
Certification Date: 08/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4911 S MERIDIAN AVE
WICHITA KS
67217-3709
US

IV. Provider business mailing address

4911 S MERIDIAN AVE
WICHITA KS
67217-3709
US

V. Phone/Fax

Practice location:
  • Phone: 316-806-1588
  • Fax: 316-352-7646
Mailing address:
  • Phone: 316-806-1588
  • Fax: 316-352-7646

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: