Provider Demographics
NPI:1790770287
Name:CHENEY GOLDEN AGE HOME, INC.
Entity Type:Organization
Organization Name:CHENEY GOLDEN AGE HOME, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:ACHILLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:316-540-3691
Mailing Address - Street 1:PO BOX 370
Mailing Address - Street 2:
Mailing Address - City:CHENEY
Mailing Address - State:KS
Mailing Address - Zip Code:67025-0370
Mailing Address - Country:US
Mailing Address - Phone:316-540-3691
Mailing Address - Fax:316-542-0165
Practice Address - Street 1:724 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CHENEY
Practice Address - State:KS
Practice Address - Zip Code:67025-9059
Practice Address - Country:US
Practice Address - Phone:316-540-3691
Practice Address - Fax:316-542-0165
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-12
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS100108890A313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100108890AMedicaid
KS100108890AMedicaid