Basic Information
| Provider Information | |||||||||
| NPI: | 1134117708 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LIBERTY SENIOR LIVING -N H L L C | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | OAK RIDGE ACRES NURSING FACILITY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 201 SIOUX AVE | ||||||||
| Address2: | |||||||||
| City: | HIAWATHA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 664342756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7857422149 | ||||||||
| FaxNumber: | 7857422881 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 SIOUX AVE | ||||||||
| Address2: | |||||||||
| City: | HIAWATHA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 664342756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7857422149 | ||||||||
| FaxNumber: | 7857422881 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WOLNEY | ||||||||
| AuthorizedOfficialFirstName: | DENISE | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7857422149 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MBA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | N007002 | KS | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.