Provider Demographics
NPI:1144455312
Name:MY SACRED HOME, LLC
Entity type:Organization
Organization Name:MY SACRED HOME, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING AND CODING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:L
Authorized Official - Last Name:MANZANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:316-440-4820
Mailing Address - Street 1:7829 E ROCKHILL ST STE 406
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-3915
Mailing Address - Country:US
Mailing Address - Phone:316-440-4820
Mailing Address - Fax:316-440-4851
Practice Address - Street 1:7829 E ROCKHILL ST STE 406
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-3915
Practice Address - Country:US
Practice Address - Phone:316-440-4820
Practice Address - Fax:316-440-4851
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-18
Last Update Date:2009-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based