Provider Demographics
NPI:1336629856
Name:MARJORIES HOME OF KINGMAN, LLC
Entity type:Organization
Organization Name:MARJORIES HOME OF KINGMAN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:REGIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:316-213-9816
Mailing Address - Street 1:30912 W 23RD ST S
Mailing Address - Street 2:
Mailing Address - City:GARDEN PLAIN
Mailing Address - State:KS
Mailing Address - Zip Code:67050-9050
Mailing Address - Country:US
Mailing Address - Phone:316-213-9816
Mailing Address - Fax:
Practice Address - Street 1:1211 W KELLY AVE
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:KS
Practice Address - Zip Code:67068-8168
Practice Address - Country:US
Practice Address - Phone:316-213-9816
Practice Address - Fax:620-553-5045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-14
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSB048002251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSB048002Medicaid