1326205253 NPI number — ELDERCARE OF MID-MISSOURI V, 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 1326205253 NPI number — ELDERCARE OF MID-MISSOURI V, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELDERCARE OF MID-MISSOURI V, 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:
STONEBRIDGE LAKE OZARK
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:
1326205253
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/01/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2500 S OLD HIGHWAY 94
Provider Second Line Business Mailing Address:
SUITE 104
Provider Business Mailing Address City Name:
SAINT CHARLES
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63303-5616
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
636-477-3280
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
872 COLLEGE BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OSAGE BEACH
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65065-8408
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-302-0900
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/19/2008

Additional Information

Authorized Official

Authorized Official Last Name:
LIERMAN
Authorized Official First Name:
MARK
Authorized Official Middle Name:
Authorized Official Title or Position:
SECRETARY-TREASURER
Authorized Official Telephone Number:
636-477-3280

Provider Taxonomy Codes

  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 108303207 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com