MEDICARE: JOHN KNOX VILLAGE

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	363L00000X	Nurse Practitioner	2011034116	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DT2931	OTHER	MO	RR
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1609118702
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOHN KNOX VILLAGE

Provider Business Mailing Address
First Line	:	PO BOX 25010
Second Line	:
City	:	OVERLAND PARK
State	:	KS
Zip	:	66225-5010
Country	:	US
Telephone Number	:	913-642-4900
Fax Number	:	913-381-0979

Provider Business Practice Location Address
First Line	:	600 NW PRYOR RD
Second Line	:
City	:	LEES SUMMIT
State	:	MO
Zip	:	64081-1104
Country	:	US
Telephone Number	:	913-642-4900
Fax Number	:	913-381-0979

Authorized Official
Title or Position	:	VP - HEALTH & RESIDENT SERVICES
Name	:	RODNEY MCBRIDE
Credential	:
Telephone Number	:	816-347-2030

Provider Enumeration Date	:	03/27/2013
Last Update Date	:	03/27/2013

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