Provider Demographics
NPI:1780679498
Name:WHEAT STATE MANOR, INC
Entity Type:Organization
Organization Name:WHEAT STATE MANOR, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:316-799-2181
Mailing Address - Street 1:601 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WHITEWATER
Mailing Address - State:KS
Mailing Address - Zip Code:67154-9700
Mailing Address - Country:US
Mailing Address - Phone:316-799-2181
Mailing Address - Fax:316-799-2962
Practice Address - Street 1:601 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WHITEWATER
Practice Address - State:KS
Practice Address - Zip Code:67154-9700
Practice Address - Country:US
Practice Address - Phone:316-799-2181
Practice Address - Fax:316-799-2962
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-19
Last Update Date:2010-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSN008006314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100107400AMedicaid
KS001520OtherBCBSKS
KS100107400AMedicaid