Provider Demographics
NPI:1003321696
Name:GRACE COTTAGE LLC
Entity Type:Organization
Organization Name:GRACE COTTAGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DON/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:REGINA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:BSN RN
Authorized Official - Phone:316-990-2366
Mailing Address - Street 1:531 N CRESTLINE ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67212-4618
Mailing Address - Country:US
Mailing Address - Phone:316-990-2366
Mailing Address - Fax:316-990-2373
Practice Address - Street 1:531 N CRESTLINE ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67212-4618
Practice Address - Country:US
Practice Address - Phone:316-990-2366
Practice Address - Fax:316-990-2373
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-05
Last Update Date:2017-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSB087219310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility