Provider Demographics
NPI:1780820977
Name:BETHESDA LUTHERAN COMMUNITIES
Entity Type:Organization
Organization Name:BETHESDA LUTHERAN COMMUNITIES
Other - Org Name:FAITH VILLAGE II
Other - Org Type:Other Name
Authorized Official - Title/Position:VP OF LEGAL AFFAIRS
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:A
Authorized Official - Last Name:KACZMARSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-206-4406
Mailing Address - Street 1:14175 W 113 ST
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE MISSION
Mailing Address - State:KS
Mailing Address - Zip Code:66215
Mailing Address - Country:US
Mailing Address - Phone:913-906-5000
Mailing Address - Fax:913-469-4028
Practice Address - Street 1:14150 W 113TH ST
Practice Address - Street 2:
Practice Address - City:SHAWNEE MISSION
Practice Address - State:KS
Practice Address - Zip Code:66215-4819
Practice Address - Country:US
Practice Address - Phone:913-906-5000
Practice Address - Fax:913-469-4028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-18
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100108390CMedicaid