Provider Demographics
NPI:1669967436
Name:MEDICALODGES, INC.
Entity type:Organization
Organization Name:MEDICALODGES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:HINES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:620-709-0305
Mailing Address - Street 1:PO BOX 509
Mailing Address - Street 2:
Mailing Address - City:COFFEYVILLE
Mailing Address - State:KS
Mailing Address - Zip Code:67337-0509
Mailing Address - Country:US
Mailing Address - Phone:620-251-6700
Mailing Address - Fax:
Practice Address - Street 1:1401 CHERRY LN
Practice Address - Street 2:
Practice Address - City:GREAT BEND
Practice Address - State:KS
Practice Address - Zip Code:67530-3152
Practice Address - Country:US
Practice Address - Phone:620-792-2165
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEDICALODGES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-06-25
Last Update Date:2018-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100107470AMedicaid