Provider Demographics
NPI:1316908163
Name:VILLAGE SHALOM, INC
Entity type:Organization
Organization Name:VILLAGE SHALOM, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:EARL
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:913-266-8400
Mailing Address - Street 1:5500 W 123RD ST
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66209-3193
Mailing Address - Country:US
Mailing Address - Phone:913-317-2600
Mailing Address - Fax:
Practice Address - Street 1:5500 W 123RD ST
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66209-3193
Practice Address - Country:US
Practice Address - Phone:913-317-2600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-31
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSN046054311500000X, 261QA0600X, 310400000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100112060AMedicaid
KS90924016OtherBCBS PROVIDER NUMBER
KS100112060AMedicaid