Basic Information
| Provider Information | |||||||||
| NPI: | 1730279480 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BLUE VALLEY HEALTH CARE, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | CAMBRIDGE PLACE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 N 16TH ST | ||||||||
| Address2: | |||||||||
| City: | MARYSVILLE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 665081126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7855625321 | ||||||||
| FaxNumber: | 7855625398 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 N 16TH ST | ||||||||
| Address2: | |||||||||
| City: | MARYSVILLE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 665081126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7855625321 | ||||||||
| FaxNumber: | 7855625398 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WESSEL | ||||||||
| AuthorizedOfficialFirstName: | ARLENE | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7855625321 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | N0580003 | KS | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 1042116201 | 05 | KS | MEDICAID |