Provider Demographics
NPI:1629009337
Name:CLYDE DEVELOPMENT INC
Entity Type:Organization
Organization Name:CLYDE DEVELOPMENT INC
Other - Org Name:PARK VILLA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR/SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:L
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:ACHA, LBSW
Authorized Official - Phone:785-446-2518
Mailing Address - Street 1:114 SOUTH HIGH
Mailing Address - Street 2:
Mailing Address - City:CLYDE
Mailing Address - State:KS
Mailing Address - Zip Code:66938-9472
Mailing Address - Country:US
Mailing Address - Phone:785-446-2818
Mailing Address - Fax:785-446-2288
Practice Address - Street 1:114 SOUTH HIGH
Practice Address - Street 2:
Practice Address - City:CLYDE
Practice Address - State:KS
Practice Address - Zip Code:66938-9472
Practice Address - Country:US
Practice Address - Phone:785-446-2818
Practice Address - Fax:785-446-2288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS314000000X314000000X
KSN015005310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100109300AMedicaid
KS420022Medicare ID - Type UnspecifiedFLU SHOT PROVIDER NUMBER
KS175492Medicare ID - Type UnspecifiedMEDICARE LEGACY NUMBER