Basic Information
| Provider Information | |||||||||
| NPI: | 1851479216 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEDICALODGES, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | MEDICALODGES GODDARD | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 11/02/2006 | ||||||||
| LastUpdateDate: | 06/23/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FISHER | ||||||||
| AuthorizedOfficialFirstName: | CATHY | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6202516700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA0600X | N087012 | KS | N | Ambulatory Health Care Facilities | Clinic/Center | Adult Day Care | 332B00000X | N087012 | KS | N | Suppliers | Durable Medical Equipment & Medical Supplies | 332BC3200X | N087012 | KS | N | Suppliers | Durable Medical Equipment & Medical Supplies | Customized Equipment | 251E00000X | N087012 | KS | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 100021620D | 05 | KS | MEDICAID |