=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932157708
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GLENWOOD ESTATE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2006
-----------------------------------------------------
Last Update Date | 04/27/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1000 MULBERRY ST
-----------------------------------------------------
City | INDEPENDENCE
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67301-2026
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 620-331-8789
-----------------------------------------------------
Fax | 620-331-6895
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1000 MULBERRY ST P.O. BOX 627
-----------------------------------------------------
City | INDEPENDENCE
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67301-2026
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 620-331-8789
-----------------------------------------------------
Fax | 620-331-6895
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MARY ANN POLLOCK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 620-331-8789
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 313M00000X
-----------------------------------------------------
Taxonomy Name | Nursing Facility/Intermediate Care Facility
-----------------------------------------------------
License Number | N063017
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | N063017
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------