Provider Demographics
NPI:1700212248
Name:SHADY COTTAGE
Entity Type:Organization
Organization Name:SHADY COTTAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:785-527-2729
Mailing Address - Street 1:1302 K ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:KS
Mailing Address - Zip Code:66935-1801
Mailing Address - Country:US
Mailing Address - Phone:785-527-2729
Mailing Address - Fax:
Practice Address - Street 1:1411 17TH ST
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:KS
Practice Address - Zip Code:66935-3028
Practice Address - Country:US
Practice Address - Phone:785-527-2650
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-16
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200688530BOtherKMAP ID NUMBER