1114911435 NPI number — DEACONESS LONG TERM CARE OF MISSOURI, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114911435 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:
MONETT HEALTH 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:
1114911435
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/23/2009
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:
410 W BENTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONETT
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65708-1608
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-235-6031
Provider Business Practice Location Address Fax Number:
417-235-8676
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:  029420 , 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: 5938513 . This is a "AETNA" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 101481208 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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