Provider Demographics
NPI:1134159452
Name:PRAIRIE MISSION RETIREMENT VILLAGE
Entity type:Organization
Organization Name:PRAIRIE MISSION RETIREMENT VILLAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:K
Authorized Official - Last Name:THORNTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:620-449-2400
Mailing Address - Street 1:242 CARROLL ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:KS
Mailing Address - Zip Code:66771-4044
Mailing Address - Country:US
Mailing Address - Phone:620-449-2400
Mailing Address - Fax:620-449-2564
Practice Address - Street 1:242 CARROLL ST
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:KS
Practice Address - Zip Code:66771-4044
Practice Address - Country:US
Practice Address - Phone:620-449-2400
Practice Address - Fax:620-449-2564
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSN-067-007314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS17-5468Medicare ID - Type UnspecifiedMEDICARE