Provider Demographics
NPI:1992240675
Name:HOMESTEAD OF RUSSELL OPERATIONS, LLC
Entity type:Organization
Organization Name:HOMESTEAD OF RUSSELL OPERATIONS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:TRYON
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:785-272-1535
Mailing Address - Street 1:3715 SW 29TH ST STE 200
Mailing Address - Street 2:
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66614-2164
Mailing Address - Country:US
Mailing Address - Phone:785-272-1535
Mailing Address - Fax:785-272-1480
Practice Address - Street 1:1070 E WICHITA AVE
Practice Address - Street 2:
Practice Address - City:RUSSELL
Practice Address - State:KS
Practice Address - Zip Code:67665-2409
Practice Address - Country:US
Practice Address - Phone:785-483-5882
Practice Address - Fax:785-483-2797
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-04
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSN084007310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSN084007Medicaid