Provider Demographics
NPI:1558495325
Name:CENTER FOR INDEPENDENT LIVING SOUTHWEST KANSAS
Entity Type:Organization
Organization Name:CENTER FOR INDEPENDENT LIVING SOUTHWEST KANSAS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TROY
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:HORTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:620-276-1900
Mailing Address - Street 1:1802 E SPRUCE ST
Mailing Address - Street 2:PO BOX 2090
Mailing Address - City:GARDEN CITY
Mailing Address - State:KS
Mailing Address - Zip Code:67846-6337
Mailing Address - Country:US
Mailing Address - Phone:620-276-1900
Mailing Address - Fax:620-271-0200
Practice Address - Street 1:1802 E SPRUCE ST
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:KS
Practice Address - Zip Code:67846-6337
Practice Address - Country:US
Practice Address - Phone:620-276-1900
Practice Address - Fax:620-271-0200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100318180BMedicaid
KS100318180CMedicaid
KS100318180AMedicaid
KS100318180DMedicaid