Provider Demographics
NPI:1851569818
Name:MYSTERE LIVING & HEALTHCARE, INC.
Entity Type:Organization
Organization Name:MYSTERE LIVING & HEALTHCARE, INC.
Other - Org Name:WELLSVILLE HEALTH & REHAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:G
Authorized Official - Last Name:AVERILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:785-883-4101
Mailing Address - Street 1:304 W 7TH ST
Mailing Address - Street 2:
Mailing Address - City:WELLSVILLE
Mailing Address - State:KS
Mailing Address - Zip Code:66092-7800
Mailing Address - Country:US
Mailing Address - Phone:785-883-4101
Mailing Address - Fax:
Practice Address - Street 1:304 W 7TH ST
Practice Address - Street 2:
Practice Address - City:WELLSVILLE
Practice Address - State:KS
Practice Address - Zip Code:66092-7800
Practice Address - Country:US
Practice Address - Phone:785-883-4101
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-13
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
310400000X
KSN030004314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS2011567760BMedicaid