Basic Information
| Provider Information | |||||||||
| NPI: | 1164912911 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SRZ OP LEES SUMMIT LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | POLARIS HEALTH & WELLNESS OF LEE'S SUMMIT POINTE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 22 HERRICK DR | ||||||||
| Address2: | |||||||||
| City: | LAWRENCE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115591528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9299280307 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1501 SW 3RD ST | ||||||||
| Address2: | |||||||||
| City: | LEES SUMMIT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 64081 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8165256300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2018 | ||||||||
| LastUpdateDate: | 09/16/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GOLDNER | ||||||||
| AuthorizedOfficialFirstName: | SAMUEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | AUTHORIZED PERSON/OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 3476770448 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SRZ OP HOLDINGS LLC | ||||||||
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| NPICertificationDate: | 09/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.