Provider Demographics
NPI:1447335344
Name:PROTECTION VALLEY MANOR, INC.
Entity type:Organization
Organization Name:PROTECTION VALLEY MANOR, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SWEDE
Authorized Official - Middle Name:CLAYTON
Authorized Official - Last Name:SWAGERTY
Authorized Official - Suffix:
Authorized Official - Credentials:ACHA
Authorized Official - Phone:620-622-4261
Mailing Address - Street 1:600 S. BROADWAY
Mailing Address - Street 2:
Mailing Address - City:PROTECTION
Mailing Address - State:KS
Mailing Address - Zip Code:67127-8801
Mailing Address - Country:US
Mailing Address - Phone:620-622-4261
Mailing Address - Fax:620-622-4270
Practice Address - Street 1:600 S. BROADWAY
Practice Address - Street 2:
Practice Address - City:PROTECTION
Practice Address - State:KS
Practice Address - Zip Code:67127-8801
Practice Address - Country:US
Practice Address - Phone:620-622-4261
Practice Address - Fax:620-622-4270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSNO172002313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100109200AMedicaid