Provider Demographics
NPI:1346587326
Name:OXFORD DERBY MEMORY CARE, LLC
Entity Type:Organization
Organization Name:OXFORD DERBY MEMORY CARE, LLC
Other - Org Name:GLEN CARR HOUSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:WILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:316-201-3210
Mailing Address - Street 1:125 N MARKET ST
Mailing Address - Street 2:SUITE 1416
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67202-1721
Mailing Address - Country:US
Mailing Address - Phone:316-201-3210
Mailing Address - Fax:
Practice Address - Street 1:1433 N HAMILTON DR
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:KS
Practice Address - Zip Code:67037-8919
Practice Address - Country:US
Practice Address - Phone:316-788-9999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-10
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSN087073311500000X
KSN087078311500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)