Provider Demographics
NPI:1073647459
Name:SEDGWICK COUNTY MEMORIAL HOSPITAL AND NURSING HOME
Entity Type:Organization
Organization Name:SEDGWICK COUNTY MEMORIAL HOSPITAL AND NURSING HOME
Other - Org Name:SEDGWICK COUNTY NURSING HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:N
Authorized Official - Last Name:GOSHE
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:970-474-3323
Mailing Address - Street 1:901 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:JULESBURG
Mailing Address - State:CO
Mailing Address - Zip Code:80737-1120
Mailing Address - Country:US
Mailing Address - Phone:970-474-3323
Mailing Address - Fax:970-474-9974
Practice Address - Street 1:901 CEDAR ST
Practice Address - Street 2:
Practice Address - City:JULESBURG
Practice Address - State:CO
Practice Address - Zip Code:80737-1120
Practice Address - Country:US
Practice Address - Phone:970-474-3323
Practice Address - Fax:970-474-9974
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1269313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO05653886Medicaid