Healthcare Provider Details

I. General information

NPI: 1477707065
Provider Name (Legal Business Name): MY SACRED HOME, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2008
Last Update Date: 06/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7829 E ROCKHILL ST STE 406
WICHITA KS
67206-3920
US

IV. Provider business mailing address

7829 E ROCKHILL ST STE 406
WICHITA KS
67206-3920
US

V. Phone/Fax

Practice location:
  • Phone: 316-440-4820
  • Fax: 316-440-4851
Mailing address:
  • Phone: 316-440-4820
  • Fax: 316-440-4851

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number4135166
License Number StateKS

VIII. Authorized Official

Name: JANNIFER SUE HELMS-TERRY
Title or Position: PRESIDENT
Credential: RN
Phone: 316-708-3236