Provider Demographics
NPI:1689992752
Name:ANDOVER SENIOR CARE, LLC
Entity Type:Organization
Organization Name:ANDOVER SENIOR CARE, LLC
Other - Org Name:VICTORIA FALLS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:BUSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:316-733-2645
Mailing Address - Street 1:PO BOX 906
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:KS
Mailing Address - Zip Code:67002-0906
Mailing Address - Country:US
Mailing Address - Phone:316-733-0654
Mailing Address - Fax:316-733-0995
Practice Address - Street 1:224 E CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:KS
Practice Address - Zip Code:67002
Practice Address - Country:US
Practice Address - Phone:316-733-0654
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-13
Last Update Date:2015-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS175520OtherPTAN
KS200363120AMedicaid
KSN008012OtherKANSAS DEPARTMENT ON AGING
KS175520Medicare Oscar/Certification
KSN008012OtherKANSAS DEPARTMENT ON AGING