1629052915 NPI number — MID AMERICA HEALTHCARE LP

Table of content: (NPI 1629052915)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629052915 NPI number — MID AMERICA HEALTHCARE LP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MID AMERICA HEALTHCARE LP
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:
MARYMOUNT MANOR ASSISTED LIVING
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:
1629052915
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1749 GILSINN LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FENTON
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63026-2003
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
636-349-2311
Provider Business Mailing Address Fax Number:
636-349-6491

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
313 AUGUSTINE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EUREKA
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63025-1935
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
636-938-6770
Provider Business Practice Location Address Fax Number:
636-938-3742
Provider Enumeration Date:
12/01/2005

Additional Information

Authorized Official

Authorized Official Last Name:
RILEY
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
J
Authorized Official Title or Position:
MANAGING PARTNER
Authorized Official Telephone Number:
636-349-2311

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  031631 , 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)





Copyright © 2007-2024 www.npivalidator.com