1740273176 NPI number — DEACONESS LONG TERM CARE OF MISSOURI, INC.

Table of content: (NPI 1740273176)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740273176 NPI number — DEACONESS LONG TERM CARE OF MISSOURI, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEACONESS LONG TERM CARE OF MISSOURI, 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:
COUNTRY AIRE RETIREMENT ESTATES
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:
1740273176
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/07/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
440 LAFAYETTE AVE
Provider Second Line Business Mailing Address:
SUITE 400
Provider Business Mailing Address City Name:
CINCINNATI
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45220-1022
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-487-3600
Provider Business Mailing Address Fax Number:
513-487-3653

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18540 STATE HIGHWAY 16
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEWISTOWN
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63452-2111
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-215-2216
Provider Business Practice Location Address Fax Number:
573-215-2733
Provider Enumeration Date:
08/31/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BROOKS
Authorized Official First Name:
CARLA
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
513-487-3600

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  029664 , 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: 103108304 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5733217 . This is a "AETNA" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".