Basic Information
| Provider Information | |||||||||
| NPI: | 1316058373 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRESBYTERIAN MANORS, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ABERDEEN VILLAGE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 20440 | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672081440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166851100 | ||||||||
| FaxNumber: | 3166852900 | ||||||||
| Practice Location | |||||||||
| Address1: | 17500 W 119TH ST | ||||||||
| Address2: | |||||||||
| City: | OLATHE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660619524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9135996100 | ||||||||
| FaxNumber: | 9135993810 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 01/20/2015 | ||||||||
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| AuthorizedOfficialLastName: | WOODSMALL | ||||||||
| AuthorizedOfficialFirstName: | BEVERLY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO/TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 3166526242 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PRESBYTERIAN MANORS, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | N/A | KS | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 100112090A | 05 | KS | MEDICAID | 17D0988082 | 01 | KS | CLIA | OTHER | 709612 | 01 | KS | BLUE CROSS | OTHER |