Provider Demographics
NPI:1265587356
Name:BETHESDA LUTHERAN COMMUNITIES
Entity type:Organization
Organization Name:BETHESDA LUTHERAN COMMUNITIES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF LEGAL AFFAIRS OFFICER
Authorized Official - Prefix:
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 1:14150 W 113TH ST
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE MISSION
Mailing Address - State:KS
Mailing Address - Zip Code:66215-4819
Mailing Address - Country:US
Mailing Address - Phone:913-906-9009
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:913-906-5009
Practice Address - Fax:913-469-4028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0841302101251B00000X
KS320900000X
KS1141302101310500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310500000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Mental Illness
No251B00000XAgenciesCase Management
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100108390BMedicaid
KS100108390DMedicaid
KS100045140KMedicaid
KS100045140DMedicaid
KS100045140EMedicaid
KS100108390CMedicaid