Basic Information
| Provider Information | |||||||||
| NPI: | 1386732998 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEDICALODGES, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | MEDICALODGES GODDARD | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 501 EASY ST | ||||||||
| Address2: | |||||||||
| City: | GODDARD | ||||||||
| State: | KS | ||||||||
| PostalCode: | 670529211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3167948635 | ||||||||
| FaxNumber: | 3167943476 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 EASY ST | ||||||||
| Address2: | |||||||||
| City: | GODDARD | ||||||||
| State: | KS | ||||||||
| PostalCode: | 670529211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3167948635 | ||||||||
| FaxNumber: | 3167943476 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2006 | ||||||||
| LastUpdateDate: | 10/21/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FISHER | ||||||||
| AuthorizedOfficialFirstName: | CATHY | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6202516700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | N087012 | KS | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 100107980A | 05 | KS | MEDICAID |