MEDICARE: KANSAS MASONIC HOME

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	314000000X	Skilled Nursing Facility	N087008	KS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0578	OTHER		BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1437244654
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KANSAS MASONIC HOME

Provider Business Mailing Address
First Line	:	401 S SENECA ST
Second Line	:
City	:	WICHITA
State	:	KS
Zip	:	67213-5541
Country	:	US
Telephone Number	:	316-269-7652
Fax Number	:	316-269-7643

Provider Business Practice Location Address
First Line	:	401 S SENECA ST
Second Line	:
City	:	WICHITA
State	:	KS
Zip	:	67213-5541
Country	:	US
Telephone Number	:	316-269-7652
Fax Number	:	316-269-7643

Authorized Official
Title or Position	:	C.E.O.
Name	:	MR. MATTHEW BOGNER
Credential	:
Telephone Number	:	316-269-7650

Provider Enumeration Date	:	10/04/2006
Last Update Date	:	07/10/2015

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Directions to “KANSAS MASONIC HOME ” Practice Location

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