Basic Information
| Provider Information | |||||||||
| NPI: | 1215152012 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EMERITUS PROPERTIES XVI, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | EMERITUS AT AUGUSTA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3131 ELLIOTT AVE | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981211044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2062982909 | ||||||||
| FaxNumber: | 2063014500 | ||||||||
| Practice Location | |||||||||
| Address1: | 1611 FAIRWAY DR | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 670102246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3167751000 | ||||||||
| FaxNumber: | 3167756309 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2007 | ||||||||
| LastUpdateDate: | 09/12/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ALLEN | ||||||||
| AuthorizedOfficialFirstName: | TRACY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR MEDICAID SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 8004294828 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | N008008 | KS | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | 200297710A | 05 | KS | MEDICAID |