MEDICARE: MARJORIES HOME OF KINGMAN, 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	251J00000X	Nursing Care Agency	B048002	KS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1336629856
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARJORIES HOME OF KINGMAN, LLC

Provider Business Mailing Address
First Line	:	30912 W 23RD ST S
Second Line	:
City	:	GARDEN PLAIN
State	:	KS
Zip	:	67050-9050
Country	:	US
Telephone Number	:	316-213-9816
Fax Number	:

Provider Business Practice Location Address
First Line	:	1211 W KELLY AVE
Second Line	:
City	:	KINGMAN
State	:	KS
Zip	:	67068-8168
Country	:	US
Telephone Number	:	316-213-9816
Fax Number	:	620-553-5045

Authorized Official
Title or Position	:	OWNER
Name	:	THERESA REGIER
Credential	:
Telephone Number	:	316-213-9816

Provider Enumeration Date	:	08/14/2018
Last Update Date	:	08/14/2018

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