Provider Demographics
NPI:1164546024
Name:HUMBOLDT ASSISTED LIVING, LLC
Entity Type:Organization
Organization Name:HUMBOLDT ASSISTED LIVING, LLC
Other - Org Name:ARROWOOD LANE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGEMENT COMPANY REPRESENTATIVE
Authorized Official - Prefix:
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:WILCOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-898-1079
Mailing Address - Street 1:615 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:HUMBOLDT
Mailing Address - State:KS
Mailing Address - Zip Code:66748-1011
Mailing Address - Country:US
Mailing Address - Phone:620-473-3456
Mailing Address - Fax:620-473-2299
Practice Address - Street 1:615 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:HUMBOLDT
Practice Address - State:KS
Practice Address - Zip Code:66748-1011
Practice Address - Country:US
Practice Address - Phone:620-473-3456
Practice Address - Fax:620-473-2299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-18
Last Update Date:2015-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS100352910A251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100352910AMedicaid