=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639313067
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SENIORCARE HOMES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/29/2009
-----------------------------------------------------
Last Update Date | 04/29/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6918 W 68TH ST
-----------------------------------------------------
City | OVERLAND PARK
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66204-1301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-236-0036
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5200 W 94TH TER SUITE 115
-----------------------------------------------------
City | PRAIRIE VILLAGE
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66207-2522
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-236-0036
-----------------------------------------------------
Fax | 913-432-3055
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. JERALD LESLIE PULLINS JR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 913-236-0036
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number | B046036
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number | B046040
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------