Provider Demographics
NPI:1679560932
Name:THE LEGACY AT PARK VIEW
Entity Type:Organization
Organization Name:THE LEGACY AT PARK VIEW
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLE
Authorized Official - Middle Name:B
Authorized Official - Last Name:DOTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:620-356-3331
Mailing Address - Street 1:510 E SAN JACINTO AVE
Mailing Address - Street 2:
Mailing Address - City:ULYSSES
Mailing Address - State:KS
Mailing Address - Zip Code:67880-2241
Mailing Address - Country:US
Mailing Address - Phone:620-356-3331
Mailing Address - Fax:620-356-1932
Practice Address - Street 1:510 E SAN JACINTO AVE
Practice Address - Street 2:
Practice Address - City:ULYSSES
Practice Address - State:KS
Practice Address - Zip Code:67880-2241
Practice Address - Country:US
Practice Address - Phone:620-356-3331
Practice Address - Fax:620-356-1932
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-03
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSN034001313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100108710-BMedicaid