Provider Demographics
NPI:1326181066
Name:LEISURE HOMESTEAD ASSOCIATION
Entity Type:Organization
Organization Name:LEISURE HOMESTEAD ASSOCIATION
Other - Org Name:LEISURE HOMESTEAD AT ST JOHN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:YOUNIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:620-549-3541
Mailing Address - Street 1:402 N SANTA FE ST
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHN
Mailing Address - State:KS
Mailing Address - Zip Code:67576-1800
Mailing Address - Country:US
Mailing Address - Phone:620-549-3541
Mailing Address - Fax:620-549-3590
Practice Address - Street 1:402 N SANTA FE ST
Practice Address - Street 2:
Practice Address - City:SAINT JOHN
Practice Address - State:KS
Practice Address - Zip Code:67576-1800
Practice Address - Country:US
Practice Address - Phone:620-549-3541
Practice Address - Fax:620-549-3590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSN098001314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100110450AMedicaid
17E607OtherFEDERAL PROVIDER NO
161495OtherAAHSA ID NO
17E607OtherFEDERAL PROVIDER NO