Provider Demographics
NPI:1316017544
Name:MEDICALODGES, INC.
Entity Type:Organization
Organization Name:MEDICALODGES, INC.
Other - Org Name:GRAN VILLAS NEOSHO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:W
Authorized Official - Last Name:FISHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:620-251-6700
Mailing Address - Street 1:420 W LYON DR
Mailing Address - Street 2:
Mailing Address - City:NEOSHO
Mailing Address - State:MO
Mailing Address - Zip Code:64850-9194
Mailing Address - Country:US
Mailing Address - Phone:417-451-7071
Mailing Address - Fax:417-451-5127
Practice Address - Street 1:420 W LYON DR
Practice Address - Street 2:
Practice Address - City:NEOSHO
Practice Address - State:MO
Practice Address - Zip Code:64850-9194
Practice Address - Country:US
Practice Address - Phone:417-451-7071
Practice Address - Fax:417-451-5127
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO031639251E00000X, 261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO031639Medicaid
MO268025509Medicaid