Provider Demographics
NPI:1750385217
Name:PROVIDENCE PLACE, INC.
Entity type:Organization
Organization Name:PROVIDENCE PLACE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:WARREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:913-596-4200
Mailing Address - Street 1:8909 PARALLEL PKWY
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66112-1689
Mailing Address - Country:US
Mailing Address - Phone:913-596-4200
Mailing Address - Fax:913-596-4904
Practice Address - Street 1:8909 PARALLEL PKWY
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66112-1689
Practice Address - Country:US
Practice Address - Phone:913-596-4200
Practice Address - Fax:913-596-4904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-10
Last Update Date:2013-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSN105013314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200972460AMedicaid
KS175159Medicare Oscar/Certification