1316089030 NPI number — SENIOR LIFE, 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 1316089030 NPI number — SENIOR LIFE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SENIOR LIFE, 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:
SAXTON RIVERSIDE 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:
1316089030
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/11/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 8359
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST. JOSEPH
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64508-8359
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
816-232-9874
Provider Business Mailing Address Fax Number:
816-364-4454

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1616 WEISENBORN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT JOSEPH
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64507-2527
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-232-9874
Provider Business Practice Location Address Fax Number:
816-364-4454
Provider Enumeration Date:
02/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SAXTON
Authorized Official First Name:
TIMOTHY
Authorized Official Middle Name:
DELMAR
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
816-364-2578

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  033685 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 313M00000X , with the licence number: 033652 , 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: 102051604 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 262051600 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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