1316017544 NPI number — MEDICALODGES, INC.

Table of content: (NPI 1316017544)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316017544 NPI number — MEDICALODGES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDICALODGES, INC.
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:
GRAN VILLAS NEOSHO
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:
1316017544
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/19/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
420 W LYON DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEOSHO
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64850-9194
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-451-7071
Provider Business Mailing Address Fax Number:
417-451-5127

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
420 W LYON DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEOSHO
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64850-9194
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-451-7071
Provider Business Practice Location Address Fax Number:
417-451-5127
Provider Enumeration Date:
11/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FISHER
Authorized Official First Name:
CATHY
Authorized Official Middle Name:
W
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
620-251-6700

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  031639 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QA0600X , with the licence number: 031639 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 031639 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 268025509 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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