Provider Demographics
NPI:1962940288
Name:MOC WICHITA LLC
Entity type:Organization
Organization Name:MOC WICHITA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED REPRESENTATIVE
Authorized Official - Prefix:
Authorized Official - First Name:ANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN ZEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-582-6932
Mailing Address - Street 1:14390 CLAY TERRACE BLVD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-3627
Mailing Address - Country:US
Mailing Address - Phone:317-582-6932
Mailing Address - Fax:
Practice Address - Street 1:7057 W VILLAGE CIRCLE
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67205
Practice Address - Country:US
Practice Address - Phone:317-582-6932
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-07
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility