Provider Demographics
NPI:1518954569
Name:MID-AMERICA AT PEABODY, LLC
Entity Type:Organization
Organization Name:MID-AMERICA AT PEABODY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:ADMINISTRATOR
Authorized Official - Phone:620-983-2152
Mailing Address - Street 1:407 N LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:PEABODY
Mailing Address - State:KS
Mailing Address - Zip Code:66866-1117
Mailing Address - Country:US
Mailing Address - Phone:620-983-2152
Mailing Address - Fax:620-983-2281
Practice Address - Street 1:407 N LOCUST ST
Practice Address - Street 2:
Practice Address - City:PEABODY
Practice Address - State:KS
Practice Address - Zip Code:66866-1117
Practice Address - Country:US
Practice Address - Phone:620-983-2152
Practice Address - Fax:620-983-2281
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-04
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS100419260A251E00000X, 261QA0600X
KS100107310A314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No251E00000XAgenciesHome Health
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100107310AMedicaid
KS100419260AMedicaid
KS175457Medicare Oscar/Certification
KS175457Medicare ID - Type Unspecified