Healthcare Provider Details

I. General information

NPI: 1275656035
Provider Name (Legal Business Name): BIG LAKES DEVELOPMENTAL CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 03/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1416 HAYES DR
MANHATTAN KS
66502-5066
US

IV. Provider business mailing address

1416 HAYES DR
MANHATTAN KS
66502-5066
US

V. Phone/Fax

Practice location:
  • Phone: 785-776-9201
  • Fax: 785-776-9830
Mailing address:
  • Phone: 785-776-9201
  • Fax: 785-776-9830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number StateKS
# 5
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number StateKS

VIII. Authorized Official

Name: PHILLIP KORENEK
Title or Position: CFO
Credential:
Phone: 785-776-9201