Provider Demographics
NPI:1538257134
Name:MEDICALODGES, INC.
Entity type:Organization
Organization Name:MEDICALODGES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:L
Authorized Official - Last Name:HINES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:620-709-0305
Mailing Address - Street 1:400 W LYON DR
Mailing Address - Street 2:
Mailing Address - City:NEOSHO
Mailing Address - State:MO
Mailing Address - Zip Code:64850-9194
Mailing Address - Country:US
Mailing Address - Phone:417-451-2544
Mailing Address - Fax:417-451-3221
Practice Address - Street 1:400 W LYON DR
Practice Address - Street 2:
Practice Address - City:NEOSHO
Practice Address - State:MO
Practice Address - Zip Code:64850-9194
Practice Address - Country:US
Practice Address - Phone:417-451-2544
Practice Address - Fax:417-451-3221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO026690314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO101451805Medicaid
MO265266Medicare Oscar/Certification
MO0411980025Medicare ID - Type Unspecified