=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255033759
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOHN KNOX VILLAGE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/20/2023
-----------------------------------------------------
Last Update Date | 03/20/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5350 W 94TH TER STE 205
-----------------------------------------------------
City | PRAIRIE VILLAGE
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66207-2520
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-403-8343
-----------------------------------------------------
Fax | 913-262-5854
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 400 NW MURRAY RD
-----------------------------------------------------
City | LEES SUMMIT
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64081-1498
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-347-2109
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT, HEALTH SERVICES
-----------------------------------------------------
Name | ANTHONY COLUMBATTO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 816-347-2030
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251G00000X
-----------------------------------------------------
Taxonomy Name | Community Based Hospice Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------