Provider Demographics
NPI:1134286859
Name:KINGMAN COUNTY RETIREMENT HOME ASSOCIATION
Entity Type:Organization
Organization Name:KINGMAN COUNTY RETIREMENT HOME ASSOCIATION
Other - Org Name:THE WHEATLANDS HEALTH CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BOARD PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:KEENY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:620-532-5801
Mailing Address - Street 1:750 W WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:KS
Mailing Address - Zip Code:67068-2000
Mailing Address - Country:US
Mailing Address - Phone:620-532-5801
Mailing Address - Fax:620-532-5587
Practice Address - Street 1:750 W WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:KS
Practice Address - Zip Code:67068-2000
Practice Address - Country:US
Practice Address - Phone:620-532-5801
Practice Address - Fax:620-532-5587
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS100072620A310400000X
KS100111790A313M00000X
KS175521314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100111790AMedicaid
KS100072620AMedicaid