Provider Demographics
NPI:1518069673
Name:GOOD SHEPHERD HOSPICE WICHITA LLC
Entity Type:Organization
Organization Name:GOOD SHEPHERD HOSPICE WICHITA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:KYLE
Authorized Official - Last Name:DELESTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-943-0903
Mailing Address - Street 1:7829 E ROCKHILL
Mailing Address - Street 2:STE 403
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206
Mailing Address - Country:US
Mailing Address - Phone:316-616-2277
Mailing Address - Fax:316-616-2288
Practice Address - Street 1:7829 E ROCKHILL
Practice Address - Street 2:STE 403
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206
Practice Address - Country:US
Practice Address - Phone:316-616-2277
Practice Address - Fax:316-616-2288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-01
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS379858251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200385740AMedicaid
KS200385740AMedicaid