Provider Demographics
NPI:1417139585
Name:DESERET NURSING AND REHABILITATION AT WICHITA, INC
Entity Type:Organization
Organization Name:DESERET NURSING AND REHABILITATION AT WICHITA, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-296-5105
Mailing Address - Street 1:1600 S WOODLAWN BLVD
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67218-4728
Mailing Address - Country:US
Mailing Address - Phone:316-691-9999
Mailing Address - Fax:
Practice Address - Street 1:1600 S WOODLAWN BLVD
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67218-4728
Practice Address - Country:US
Practice Address - Phone:316-691-9999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-30
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS175452Medicare Oscar/Certification