Provider Demographics
NPI:1932458106
Name:WEST WICHITA ASSISTED LIVING, LLC
Entity Type:Organization
Organization Name:WEST WICHITA ASSISTED LIVING, LLC
Other - Org Name:AVITA SENIOR LIVING AT ROLLING HILLS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:FRED
Authorized Official - Middle Name:
Authorized Official - Last Name:HERMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:316-773-1313
Mailing Address - Street 1:7200 W 13TH
Mailing Address - Street 2:SUITE 10
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67212
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:629 S. MAIZE CT
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67209
Practice Address - Country:US
Practice Address - Phone:316-361-2550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-04
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSN087067310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility