1659363224 NPI number — CLINTON CONVALESCENT CENTER, INC.

Table of content: (NPI 1659363224)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659363224 NPI number — CLINTON CONVALESCENT CENTER, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLINTON CONVALESCENT CENTER, INC.
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:
OAKRIDGE OF PLATTSBURG
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:
1659363224
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/13/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 247
Provider Second Line Business Mailing Address:
205 E. CLAY AVE.
Provider Business Mailing Address City Name:
PLATTSBURG
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64477-0247
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
816-539-2128
Provider Business Mailing Address Fax Number:
816-539-2715

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
205 E CLAY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PLATTSBURG
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64477-8100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-539-2128
Provider Business Practice Location Address Fax Number:
816-539-2715
Provider Enumeration Date:
08/18/2005

Additional Information

Authorized Official

Authorized Official Last Name:
JONES
Authorized Official First Name:
ELIZABETH
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
816-539-2128

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  030633 , 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: 102684800 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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