Basic Information
Provider Information | |||||||||
NPI: | 1538123377 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WEST CENTRAL KANSAS ASSOCIATION, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | RUSSELL REGIONAL HOSPITAL SWINGBED | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 200 S MAIN ST | ||||||||
Address2: |   | ||||||||
City: | RUSSELL | ||||||||
State: | KS | ||||||||
PostalCode: | 676652920 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7854833131 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 200 S MAIN ST | ||||||||
Address2: |   | ||||||||
City: | RUSSELL | ||||||||
State: | KS | ||||||||
PostalCode: | 676652920 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7854833131 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/17/2006 | ||||||||
LastUpdateDate: | 08/16/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BODEN | ||||||||
AuthorizedOfficialFirstName: | SHELLEY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 7854833131 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | H084001 | KS | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 100306710A | 05 | KS |   | MEDICAID | 1639 | 01 | KS | BLUE CROSS PROVIDER NUMBE | OTHER |