=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265587356
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BETHESDA LUTHERAN COMMUNITIES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/25/2007
-----------------------------------------------------
Last Update Date | 05/11/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14150 W 113TH ST
-----------------------------------------------------
City | SHAWNEE MISSION
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66215-4819
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-906-5009
-----------------------------------------------------
Fax | 913-469-4028
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14150 W 113TH ST
-----------------------------------------------------
City | SHAWNEE MISSION
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66215-4819
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-906-9009
-----------------------------------------------------
Fax | 913-469-4028
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF LEGAL AFFAIRS OFFICER
-----------------------------------------------------
Name | JEFFREY A. KACZMARSKI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 920-206-4406
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number | 0841302101
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 320900000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 310500000X
-----------------------------------------------------
Taxonomy Name | Mental Illness Intermediate Care Facility
-----------------------------------------------------
License Number | 1141302101
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------