Healthcare Provider Details

I. General information

NPI: 1689000853
Provider Name (Legal Business Name): CASE MANAGEMENT BY KRIS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2013
Last Update Date: 09/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

561 S LOVERS LN
SCOTT CITY KS
67871-5029
US

IV. Provider business mailing address

PO BOX 295
GARDEN CITY KS
67846-0295
US

V. Phone/Fax

Practice location:
  • Phone: 620-271-2492
  • Fax:
Mailing address:
  • Phone: 620-271-2492
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number100374970A
License Number StateKS

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier100374970A
Identifier TypeMEDICAID
Identifier StateKS
Identifier Issuer

VIII. Authorized Official

Name: KRIS LUNDGREN
Title or Position: CASE MANAGER - TCM
Credential:
Phone: 620-271-2492