Basic Information
| Provider Information | |||||||||
| NPI: | 1386611226 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KINGS CAMP INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | KINGS ACHIEVEMENT CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| 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: | 3197942773 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | PAASCH | ||||||||
| AuthorizedOfficialFirstName: | DOROTHY | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3167942913 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 322D00000X | 36366002 | KS | Y | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children |
ID Information
| ID | Type | State | Issuer | Description | 103575 | 01 | KS | BLUE CROSS & BLUE SHIELD | OTHER |