MEDICARE: RL MAIZE CT 2

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	B087188	KS

General Provider Information

NPI Number	:	1740552454
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RL MAIZE CT 2

Provider Business Mailing Address
First Line	:	625 S. MAIZE CT
Second Line	:
City	:	WICHITA
State	:	KS
Zip	:	67209-2207
Country	:	US
Telephone Number	:	316-992-2119
Fax Number	:

Provider Business Practice Location Address
First Line	:	625 S. MAIZE CT
Second Line	:
City	:	WICHITA
State	:	KS
Zip	:	67209-2207
Country	:	US
Telephone Number	:	316-992-2119
Fax Number	:

Authorized Official
Title or Position	:	OWNER/OPERATOR
Name	:	MRS. SUSAN KAY ENGELS
Credential	:
Telephone Number	:	316-992-2119

Provider Enumeration Date	:	01/27/2012
Last Update Date	:	01/27/2012

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