Provider Demographics
NPI:1619123486
Name:HICKORY HEIGHTS
Entity Type:Organization
Organization Name:HICKORY HEIGHTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANJEANETTE
Authorized Official - Middle Name:T
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:785-735-9236
Mailing Address - Street 1:1202 HICKORY ST
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:KS
Mailing Address - Zip Code:67671-9310
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1202 HICKORY ST
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:KS
Practice Address - Zip Code:67671-9310
Practice Address - Country:US
Practice Address - Phone:785-735-9236
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-13
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities