Basic Information
| Provider Information | |||||||||
| NPI: | 1073574224 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTERS FOR LONG TERM CARE OF BONNER SPRINGS, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 155635 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761550635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173592000 | ||||||||
| FaxNumber: | 8173592093 | ||||||||
| Practice Location | |||||||||
| Address1: | 520 E MORSE AVE | ||||||||
| Address2: | |||||||||
| City: | BONNER SPRINGS | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660121911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9134412515 | ||||||||
| FaxNumber: | 9134412118 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | TREBERT | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8173592000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 1042073101 | 05 | KS | MEDICAID |