Basic Information
| Provider Information | |||||||||
| NPI: | 1407943699 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THI OF KANSAS AT INDIAN CREEK, LLC | ||||||||
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| OtherOrganizationName: | INDIAN CREEK HEALTHCARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 920 RIDGEBROOK RD | ||||||||
| Address2: | |||||||||
| City: | SPARKS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211529390 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107731000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6515 W 103RD ST | ||||||||
| Address2: | |||||||||
| City: | OVERLAND PARK | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662121728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9136425545 | ||||||||
| FaxNumber: | 9136423982 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2006 | ||||||||
| LastUpdateDate: | 06/21/2011 | ||||||||
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| AuthorizedOfficialLastName: | CALDWELL | ||||||||
| AuthorizedOfficialFirstName: | GLENNA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9136425545 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 1042125101 | 05 | KS | MEDICAID |