Provider Demographics
NPI:1598108680
Name:PRIME HEALTHCARE SERVICES - SAINT JOHN LEAVENWORTH LLC
Entity Type:Organization
Organization Name:PRIME HEALTHCARE SERVICES - SAINT JOHN LEAVENWORTH LLC
Other - Org Name:SAINT JOHN LEAVENWORTH PSYCHIATRIC UNIT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT OF OPERATIONS II
Authorized Official - Prefix:MR
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:
Authorized Official - Last Name:LEON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-235-4362
Mailing Address - Street 1:3500 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:LEAVENWORTH
Mailing Address - State:KS
Mailing Address - Zip Code:66048-5043
Mailing Address - Country:US
Mailing Address - Phone:909-235-4362
Mailing Address - Fax:909-235-4418
Practice Address - Street 1:3500 S 4TH ST
Practice Address - Street 2:
Practice Address - City:LEAVENWORTH
Practice Address - State:KS
Practice Address - Zip Code:66048-5043
Practice Address - Country:US
Practice Address - Phone:909-235-4362
Practice Address - Fax:909-235-4418
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-09
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS17S009Medicare Oscar/Certification