Provider Demographics
NPI:1679814610
Name:PREMIER LIVING BY WARDEN LLC
Entity type:Organization
Organization Name:PREMIER LIVING BY WARDEN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BRANDI
Authorized Official - Middle Name:
Authorized Official - Last Name:WARDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:316-945-2028
Mailing Address - Street 1:234 S ANNA ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67209-2404
Mailing Address - Country:US
Mailing Address - Phone:316-945-2028
Mailing Address - Fax:316-945-0670
Practice Address - Street 1:234 S ANNA ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67209-2404
Practice Address - Country:US
Practice Address - Phone:316-945-2028
Practice Address - Fax:316-945-0670
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-14
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSB087119313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200975520AMedicaid