Basic Information
| Provider Information | |||||||||
| NPI: | 1336263052 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EMBERHOPE, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | EMBERHOPE, INC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4505 E 47TH ST S | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672101651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3165299100 | ||||||||
| FaxNumber: | 3165299351 | ||||||||
| Practice Location | |||||||||
| Address1: | 11200 LARIAT WAY | ||||||||
| Address2: | |||||||||
| City: | DODGE CITY | ||||||||
| State: | KS | ||||||||
| PostalCode: | 678017328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6202250276 | ||||||||
| FaxNumber: | 6202250279 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2007 | ||||||||
| LastUpdateDate: | 07/01/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BULLA | ||||||||
| AuthorizedOfficialFirstName: | TOYIA | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3165299100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | UNITED METHODIST YOUTHVILLE INC | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | 0015391-001 | KS | N | Agencies | Case Management | 251B00000X | 771-1 | KS | N | Agencies | Case Management | 323P00000X | 003255006 | KS | Y | Residential Treatment Facilities | Psychiatric Residential Treatment Facility |
ID Information
| ID | Type | State | Issuer | Description | 100007290C | 05 | KS | MEDICAID |