Provider Demographics
NPI:1447393160
Name:LEISURE HOMESTEAD ASSOCIATION
Entity Type:Organization
Organization Name:LEISURE HOMESTEAD ASSOCIATION
Other - Org Name:LEISURE HOMESTEAD AT STAFFORD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUNIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:620-234-5208
Mailing Address - Street 1:405 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:KS
Mailing Address - Zip Code:67578-2009
Mailing Address - Country:US
Mailing Address - Phone:620-234-5208
Mailing Address - Fax:620-234-6911
Practice Address - Street 1:405 GRAND AVE
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:KS
Practice Address - Zip Code:67578-2009
Practice Address - Country:US
Practice Address - Phone:620-234-5208
Practice Address - Fax:620-234-6911
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
KSN093002314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS130494OtherAAHSA ID
KS100109230AMedicaid
17E581OtherFEDERAL PROVIDER NO
KSN093002OtherSTATE REGISTRY
KS17-5530Medicare PIN