Provider Demographics
NPI:1972578037
Name:MOUNDRIDGE MANOR INC.
Entity Type:Organization
Organization Name:MOUNDRIDGE MANOR INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:W
Authorized Official - Last Name:UNRUH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:620-345-6364
Mailing Address - Street 1:P.O. BOX 800
Mailing Address - Street 2:
Mailing Address - City:MOUNDRIDGE
Mailing Address - State:KS
Mailing Address - Zip Code:67107
Mailing Address - Country:US
Mailing Address - Phone:620-345-6364
Mailing Address - Fax:620-345-6376
Practice Address - Street 1:710 NORTH CHRISTIAN AVENUE
Practice Address - Street 2:
Practice Address - City:MOUNDRIDGE
Practice Address - State:KS
Practice Address - Zip Code:67107
Practice Address - Country:US
Practice Address - Phone:620-345-6364
Practice Address - Fax:620-345-6376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-22
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSN059003313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100109430AMedicaid