Provider Demographics
NPI:1710210943
Name:GARDEN VALLEY RETIREMENT VILLAGE, LLC
Entity Type:Organization
Organization Name:GARDEN VALLEY RETIREMENT VILLAGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KIKLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-952-9216
Mailing Address - Street 1:1505 EAST SPRUCE STREET
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:KS
Mailing Address - Zip Code:67846
Mailing Address - Country:US
Mailing Address - Phone:620-275-9651
Mailing Address - Fax:620-275-6582
Practice Address - Street 1:1505 EAST SPRUCE STREET
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:KS
Practice Address - Zip Code:67846
Practice Address - Country:US
Practice Address - Phone:620-275-9651
Practice Address - Fax:620-275-6582
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-04
Last Update Date:2015-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS1041134501Medicaid
KS1041134501Medicaid