Provider Demographics
NPI:1902104771
Name:PEABODY OPERATOR, LLC
Entity type:Organization
Organization Name:PEABODY OPERATOR, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:STUART
Authorized Official - Middle Name:
Authorized Official - Last Name:LINDEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-440-8345
Mailing Address - Street 1:407 N. LOCUST STREET
Mailing Address - Street 2:
Mailing Address - City:PEABODY
Mailing Address - State:KS
Mailing Address - Zip Code:66866-1117
Mailing Address - Country:US
Mailing Address - Phone:620-983-2152
Mailing Address - Fax:620-983-2281
Practice Address - Street 1:407 N. LOCUST STREET
Practice Address - Street 2:
Practice Address - City:PEABODY
Practice Address - State:KS
Practice Address - Zip Code:66866-1117
Practice Address - Country:US
Practice Address - Phone:620-983-2152
Practice Address - Fax:620-983-2281
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-03
Last Update Date:2015-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200739240AMedicaid
KS200739240AMedicaid