MEDICARE: THE LEGACY AT PARK VIEW

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	313M00000X	Nursing Facility/Intermediate Care Facility	N034001	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	:	1679560932
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE LEGACY AT PARK VIEW

Provider Business Mailing Address
First Line	:	510 E SAN JACINTO AVE
Second Line	:
City	:	ULYSSES
State	:	KS
Zip	:	67880-2241
Country	:	US
Telephone Number	:	620-356-3331
Fax Number	:	620-356-1932

Provider Business Practice Location Address
First Line	:	510 E SAN JACINTO AVE
Second Line	:
City	:	ULYSSES
State	:	KS
Zip	:	67880-2241
Country	:	US
Telephone Number	:	620-356-3331
Fax Number	:	620-356-1932

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	KIMBERLE B DOTY
Credential	:
Telephone Number	:	620-356-3331

Provider Enumeration Date	:	10/03/2005
Last Update Date	:	10/10/2012

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Directions to “THE LEGACY AT PARK VIEW ” Practice Location

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