Provider Demographics
NPI:1528155470
Name:MEDICALODGES, INC.
Entity type:Organization
Organization Name:MEDICALODGES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:V.P. OF FINANCIAL REPORTING
Authorized Official - Prefix:MS
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:W
Authorized Official - Last Name:FISHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:620-251-6700
Mailing Address - Street 1:1210 W ASHLAND ST
Mailing Address - Street 2:
Mailing Address - City:NEVADA
Mailing Address - State:MO
Mailing Address - Zip Code:64772-1906
Mailing Address - Country:US
Mailing Address - Phone:417-667-5064
Mailing Address - Fax:417-667-8154
Practice Address - Street 1:1210 W ASHLAND ST
Practice Address - Street 2:
Practice Address - City:NEVADA
Practice Address - State:MO
Practice Address - Zip Code:64772-1906
Practice Address - Country:US
Practice Address - Phone:417-667-5064
Practice Address - Fax:417-667-8154
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2009-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO032350314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO101457307Medicaid
MO265493Medicare Oscar/Certification
MO0411980027Medicare ID - Type Unspecified