Provider Demographics
NPI:1275656035
Name:BIG LAKES DEVELOPMENTAL CENTER INC
Entity Type:Organization
Organization Name:BIG LAKES DEVELOPMENTAL CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:
Authorized Official - Last Name:KORENEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:785-776-9201
Mailing Address - Street 1:1416 HAYES DR
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66502-5066
Mailing Address - Country:US
Mailing Address - Phone:785-776-9201
Mailing Address - Fax:785-776-9830
Practice Address - Street 1:1416 HAYES DR
Practice Address - Street 2:
Practice Address - City:MANHATTAN
Practice Address - State:KS
Practice Address - Zip Code:66502-5066
Practice Address - Country:US
Practice Address - Phone:785-776-9201
Practice Address - Fax:785-776-9830
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2014-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171WH0202X, 251E00000X, 3747P1801X
KS251B00000X, 251C00000X, 332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No171WH0202XOther Service ProvidersContractorHome ModificationsGroup - Multi-Specialty
No251B00000XAgenciesCase ManagementGroup - Multi-Specialty
No251E00000XAgenciesHome HealthGroup - Multi-Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Multi-Specialty
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100008410AMedicaid
KS100009080BMedicaid