1194771410 NPI number — ANDOVER MEDICAL INVESTORS, LLC

Table of content: (NPI 1194771410)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194771410 NPI number — ANDOVER MEDICAL INVESTORS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANDOVER MEDICAL INVESTORS, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
LIFE CARE CENTER OF ANDOVER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194771410
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/12/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3001 KEITH ST NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLEVELAND
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37312-3713
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-473-5751
Provider Business Mailing Address Fax Number:
423-339-8342

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
621 W 21ST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANDOVER
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67002-8498
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
316-733-1349
Provider Business Practice Location Address Fax Number:
316-733-0919
Provider Enumeration Date:
05/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CROSS
Authorized Official First Name:
CINDY
Authorized Official Middle Name:
S.
Authorized Official Title or Position:
ASSISTANT SECRETARY
Authorized Official Telephone Number:
423-473-5867

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  N008007 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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