MEDICARE: ALLIE'S VILLAGE MEMORY CARE HOMES, LLC

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	311ZA0620X	Adult Care Home Facility	B023016	KS

General Provider Information

NPI Number	:	1295164572
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALLIE'S VILLAGE MEMORY CARE HOMES, LLC

Provider Business Mailing Address
First Line	:	1701 RESEARCH PARK DR
Second Line	:
City	:	LAWRENCE
State	:	KS
Zip	:	66049-3883
Country	:	US
Telephone Number	:	785-856-4181
Fax Number	:

Provider Business Practice Location Address
First Line	:	1701 RESEARCH PARK DR
Second Line	:
City	:	LAWRENCE
State	:	KS
Zip	:	66049-3883
Country	:	US
Telephone Number	:	785-856-4181
Fax Number	:

Authorized Official
Title or Position	:	CEO/OWNER
Name	:	DIANNE ENSMINGER
Credential	:
Telephone Number	:	785-856-4181

Provider Enumeration Date	:	11/06/2013
Last Update Date	:	11/06/2013

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