1205952421 NPI number — MIDWEST HOMESTEAD OF OWASSO, LLC

Table of content: (NPI 1205952421)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205952421 NPI number — MIDWEST HOMESTEAD OF OWASSO, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIDWEST HOMESTEAD OF OWASSO, 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:
Provider Other Organization Name Type Code:
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:
1205952421
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3715 SW 29TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TOPEKA
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66614-2107
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
785-272-1535
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14701 E 86TH ST N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OWASSO
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74055-8474
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-376-2226
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
TRYON
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
D.
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
785-228-7913

Provider Taxonomy Codes

  • Taxonomy code: 313M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com