Provider Demographics
NPI:1033825963
Name:MAYBERRY SENIOR LIVING LLC
Entity Type:Organization
Organization Name:MAYBERRY SENIOR LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KRYSTA
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHMIDT
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:316-390-6941
Mailing Address - Street 1:244 N RUTAN ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67208-3329
Mailing Address - Country:US
Mailing Address - Phone:316-390-6941
Mailing Address - Fax:
Practice Address - Street 1:244 N RUTAN ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67208-3329
Practice Address - Country:US
Practice Address - Phone:316-390-6941
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-24
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No174200000XOther Service ProvidersMeals
No177F00000XOther Service ProvidersLodging