Basic Information
| Provider Information | |||||||||
| NPI: | 1174598395 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LEMONTREE ENTERPRISES, LLC DBA LIBERTY JUVENILE SERVICES & TREATMENT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2050 W 11TH ST N | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672033006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3162675710 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2050 W 11TH STREET N | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 67203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3162675710 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3162675710 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 323P00000X | 440861 | KS | Y | Residential Treatment Facilities | Psychiatric Residential Treatment Facility |
ID Information
| ID | Type | State | Issuer | Description | 000352 | 01 | KS | BCBS OF KS | OTHER | 0000105048 | 01 | KS | BCBS OF KANSAS | OTHER |