Provider Demographics
NPI:1497349039
Name:MARY ANN DVORACHEK
Entity Type:Organization
Organization Name:MARY ANN DVORACHEK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:DVORACHEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:620-365-7174
Mailing Address - Street 1:1201 N KENTUCKY ST
Mailing Address - Street 2:
Mailing Address - City:IOLA
Mailing Address - State:KS
Mailing Address - Zip Code:66749-1931
Mailing Address - Country:US
Mailing Address - Phone:620-365-7174
Mailing Address - Fax:
Practice Address - Street 1:1021 CONNECTICUT ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66044-3037
Practice Address - Country:US
Practice Address - Phone:620-365-7174
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-24
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100449780Medicaid