Provider Demographics
NPI:1689931016
Name:COVENANT PLACE OF LENEXA, INC.
Entity Type:Organization
Organization Name:COVENANT PLACE OF LENEXA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:E
Authorized Official - Last Name:GULLEDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:913-890-4782
Mailing Address - Street 1:11827 W 112TH ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66210-2726
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8505 PFLUMM RD
Practice Address - Street 2:
Practice Address - City:LENEXA
Practice Address - State:KS
Practice Address - Zip Code:66215-2461
Practice Address - Country:US
Practice Address - Phone:913-307-2000
Practice Address - Fax:913-322-0200
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COVENANT RETIREMENT SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-04-23
Last Update Date:2015-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS17E644Medicaid
KS175536Medicare Oscar/Certification