1497850978 NPI number — PARKDALE MANOR INCORPORATED

Table of content: (NPI 1497850978)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497850978 NPI number — PARKDALE MANOR INCORPORATED

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PARKDALE MANOR INCORPORATED
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PARKDALE MANOR CARE CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1497850978
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/23/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
814 W SOUTH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARYVILLE
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64468-2772
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
660-582-8161
Provider Business Mailing Address Fax Number:
660-582-2798

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
814 W SOUTH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARYVILLE
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64468-2772
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
660-582-8161
Provider Business Practice Location Address Fax Number:
660-582-2798
Provider Enumeration Date:
09/13/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SCHEULEN
Authorized Official First Name:
BENJAMIN
Authorized Official Middle Name:
C.
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
573-556-6240

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  015686 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 106867104 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".