Basic Information
| Provider Information | |||||||||
| NPI: | 1316961097 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HEALTHCARE OF WITCHITA, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | COLLEGE HILLS HEALTH & REHABILITATION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5005 E 21ST ST N | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672081604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166859291 | ||||||||
| FaxNumber: | 3166852099 | ||||||||
| Practice Location | |||||||||
| Address1: | 5005 E 21ST ST N | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672081604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166859291 | ||||||||
| FaxNumber: | 3166852099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 08/01/2008 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3166859291 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | N087018 | KS | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 1041150401 | 05 | KS | MEDICAID |