1710922208 NPI number — SENIORTRUST OF COLUMBIA, LLC

Table of content: (NPI 1710922208)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710922208 NPI number — SENIORTRUST OF COLUMBIA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SENIORTRUST OF COLUMBIA, LLC
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:
Provider Other Organization Name Type Code:
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:
1710922208
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:
1801 TOWNE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBIA
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65202-2337
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-474-6111
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1801 TOWNE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65202-2337
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-474-6111
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/18/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WEBB
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
615-890-2020

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  031176 , 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: 144819 . This is a "BCBS" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".