Basic Information
| Provider Information | |||||||||
| NPI: | 1386121507 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST LUKES HOSPITAL OF KANSAS CITY | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CRITTENTON RESIDENTAL TREATMENT FACILITY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10918 ELM AVE | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641344108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8167656600 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10918 ELM AVE | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641344108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8167656600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2018 | ||||||||
| LastUpdateDate: | 07/20/2018 | ||||||||
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| AuthorizedOfficialLastName: | NACHTIGAL | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8169329886 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 323P00000X | 295-38 | MO | Y | Residential Treatment Facilities | Psychiatric Residential Treatment Facility |
ID Information
| ID | Type | State | Issuer | Description | NONE | 01 | MO | NONE | OTHER |