Provider Demographics
NPI:1073603825
Name:COFFEY COUNTY HOSPITAL LTC
Entity Type:Organization
Organization Name:COFFEY COUNTY HOSPITAL LTC
Other - Org Name:SUNSET MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:MERRI
Authorized Official - Middle Name:
Authorized Official - Last Name:MICHAELS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:620-364-2121
Mailing Address - Street 1:801 N 4TH ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:KS
Mailing Address - Zip Code:66839-2602
Mailing Address - Country:US
Mailing Address - Phone:620-364-2121
Mailing Address - Fax:620-364-8425
Practice Address - Street 1:128 S PEARSON AVENUE
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:KS
Practice Address - Zip Code:66871
Practice Address - Country:US
Practice Address - Phone:785-733-2744
Practice Address - Fax:785-733-2514
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COFFEY COUNTY HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-13
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100110550AMedicaid