Provider Demographics
NPI:1275078065
Name:HOMESTEAD OF EL DORADO OPERATIONS LLC
Entity Type:Organization
Organization Name:HOMESTEAD OF EL DORADO OPERATIONS LLC
Other - Org Name:EL DORADO HOMESTEAD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:TRYON
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:785-272-1535
Mailing Address - Street 1:1650 E 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:EL DORADO
Mailing Address - State:KS
Mailing Address - Zip Code:67042-4300
Mailing Address - Country:US
Mailing Address - Phone:316-321-7777
Mailing Address - Fax:316-321-6115
Practice Address - Street 1:1650 E 12TH AVE
Practice Address - Street 2:
Practice Address - City:EL DORADO
Practice Address - State:KS
Practice Address - Zip Code:67042-4300
Practice Address - Country:US
Practice Address - Phone:316-321-7777
Practice Address - Fax:316-321-6115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-03
Last Update Date:2017-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSN008009310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSN008009Medicaid