Basic Information
| Provider Information | |||||||||
| NPI: | 1710172473 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SEQUEL OF KANSAS, LLC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | DBA RIVERSIDE ACADEMY, PREVIOUSLY CAMELOT OF KANSAS, LLC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1131 EAGLETREE LANE | ||||||||
| Address2: | |||||||||
| City: | HUNTSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 35801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2568803339 | ||||||||
| FaxNumber: | 2568807026 | ||||||||
| Practice Location | |||||||||
| Address1: | 2050 W. 11TH ST N, | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 67203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3162675710 | ||||||||
| FaxNumber: | 3162675710 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2007 | ||||||||
| LastUpdateDate: | 08/30/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SELL | ||||||||
| AuthorizedOfficialFirstName: | HEATHER | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3162675710 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SEQUEL OF KANSAS, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MSM | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 323P00000X | N | Residential Treatment Facilities | Psychiatric Residential Treatment Facility | 323P00000X | 62020 | KS | Y | Residential Treatment Facilities | Psychiatric Residential Treatment Facility |
ID Information
| ID | Type | State | Issuer | Description | 200540330B | 05 | KS | MEDICAID | 128807500 | 05 | WY | MEDICAID |