Provider Demographics
NPI:1457326092
Name:LAKEMARY CENTER, INC.
Entity Type:Organization
Organization Name:LAKEMARY CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF FISCAL SERVICES
Authorized Official - Prefix:MR
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:KELSEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:913-557-4000
Mailing Address - Street 1:100 LAKEMARY DR
Mailing Address - Street 2:
Mailing Address - City:PAOLA
Mailing Address - State:KS
Mailing Address - Zip Code:66071-1855
Mailing Address - Country:US
Mailing Address - Phone:913-557-4000
Mailing Address - Fax:913-557-4910
Practice Address - Street 1:100 LAKEMARY DR
Practice Address - Street 2:
Practice Address - City:PAOLA
Practice Address - State:KS
Practice Address - Zip Code:66071-1855
Practice Address - Country:US
Practice Address - Phone:913-557-4000
Practice Address - Fax:913-557-4910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-17
Last Update Date:2013-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS251C00000X, 320900000X
251E00000X, 3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No251E00000XAgenciesHome HealthGroup - Single Specialty
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100029130BMedicaid