Provider Demographics
NPI:1922446350
Name:MAIZE CCRC, LLC
Entity Type:Organization
Organization Name:MAIZE CCRC, LLC
Other - Org Name:PARK WEST PLAZA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:WETTIG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:316-616-6288
Mailing Address - Street 1:8415 E 21ST ST N STE 100
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-2959
Mailing Address - Country:US
Mailing Address - Phone:316-616-6288
Mailing Address - Fax:316-616-6255
Practice Address - Street 1:505 N MAIZE RD
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67212-4689
Practice Address - Country:US
Practice Address - Phone:316-729-4114
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JUPITER TENANT, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-06-07
Last Update Date:2013-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSN087046313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility