Basic Information
| Provider Information | |||||||||
| NPI: | 1184628646 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KINGS CAMP INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 215 | ||||||||
| Address2: | |||||||||
| City: | GODDARD | ||||||||
| State: | KS | ||||||||
| PostalCode: | 670520215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3167942913 | ||||||||
| FaxNumber: | 3167942773 | ||||||||
| Practice Location | |||||||||
| Address1: | 24401 W MACARTHUR RD | ||||||||
| Address2: | |||||||||
| City: | GODDARD | ||||||||
| State: | KS | ||||||||
| PostalCode: | 670528713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3167942913 | ||||||||
| FaxNumber: | 3167942773 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PAASCH | ||||||||
| AuthorizedOfficialFirstName: | DOROTHY | ||||||||
| AuthorizedOfficialMiddleName: | MAY | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3167942913 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320600000X | 2084P0800X | KS | N | Residential Treatment Facilities | Residential Treatment Facility, Mental Retardation and/or Developmental Disabilities | 320600000X | 251B00000X | KS | Y | Residential Treatment Facilities | Residential Treatment Facility, Mental Retardation and/or Developmental Disabilities |
ID Information
| ID | Type | State | Issuer | Description | 103575 | 01 | KS | BLUE CROSS & BLUE SHIELD | OTHER |