Provider Demographics
NPI:1821134263
Name:CUMBERNAULD VILLAGE, INC.
Entity Type:Organization
Organization Name:CUMBERNAULD VILLAGE, INC.
Other - Org Name:CUMBERNAULD VILLAGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT OF THE BOARD OF DIRECTORS
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:620-221-6924
Mailing Address - Street 1:716 TWEED OFC OFC
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:KS
Mailing Address - Zip Code:67156-1595
Mailing Address - Country:US
Mailing Address - Phone:620-221-4141
Mailing Address - Fax:620-221-4146
Practice Address - Street 1:716 TWEED OFC
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:KS
Practice Address - Zip Code:67156-1596
Practice Address - Country:US
Practice Address - Phone:620-221-4141
Practice Address - Fax:620-221-4146
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSN018009314000000X
314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100111960AMedicaid
KS100111960AMedicaid