Provider Demographics
NPI:1710172473
Name:SEQUEL OF KANSAS, LLC
Entity Type:Organization
Organization Name:SEQUEL OF KANSAS, LLC
Other - Org Name:DBA RIVERSIDE ACADEMY, PREVIOUSLY CAMELOT OF KANSAS, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:D
Authorized Official - Last Name:SELL
Authorized Official - Suffix:
Authorized Official - Credentials:MSM
Authorized Official - Phone:316-267-5710
Mailing Address - Street 1:1131 EAGLETREE LANE
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35801
Mailing Address - Country:US
Mailing Address - Phone:256-880-3339
Mailing Address - Fax:256-880-7026
Practice Address - Street 1:2050 W. 11TH ST N,
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67203
Practice Address - Country:US
Practice Address - Phone:316-267-5710
Practice Address - Fax:316-267-5710
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SEQUEL OF KANSAS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-09-06
Last Update Date:2011-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
323P00000X
KS62020323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200540330BMedicaid
WY128807500Medicaid