MEDICARE: WATERFORD VILLAGE LP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1104399971
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WATERFORD VILLAGE LP

Provider Business Mailing Address
First Line	:	15017 W 71ST TER
Second Line	:
City	:	SHAWNEE
State	:	KS
Zip	:	66216-4012
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	500 NW VESPER ST
Second Line	:
City	:	BLUE SPRINGS
State	:	MO
Zip	:	64014-2744
Country	:	US
Telephone Number	:	816-228-6337
Fax Number	:

Authorized Official
Title or Position	:	GENERAL PARTNER
Name	:	MR. JIM PEARSON
Credential	:
Telephone Number	:	913-631-0127

Provider Enumeration Date	:	01/04/2019
Last Update Date	:	01/04/2019

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Directions to “WATERFORD VILLAGE LP ” Practice Location

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