Provider Demographics
NPI:1386001857
Name:DOVE ESTATES SENIOR LIVING COMMUNITY
Entity type:Organization
Organization Name:DOVE ESTATES SENIOR LIVING COMMUNITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:JADIDIAN
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA
Authorized Official - Phone:316-550-6343
Mailing Address - Street 1:1400 S 183RD ST W
Mailing Address - Street 2:
Mailing Address - City:GODDARD
Mailing Address - State:KS
Mailing Address - Zip Code:67052-9357
Mailing Address - Country:US
Mailing Address - Phone:316-550-6343
Mailing Address - Fax:316-550-6467
Practice Address - Street 1:1400 S 183RD ST W
Practice Address - Street 2:
Practice Address - City:GODDARD
Practice Address - State:KS
Practice Address - Zip Code:67052-9357
Practice Address - Country:US
Practice Address - Phone:316-550-6343
Practice Address - Fax:316-550-6467
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-28
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSN087082310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201115690AMedicaid