1407099500 NPI number — VICTORIAN MANOR OF SULLIVAN

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 1407099500 NPI number — VICTORIAN MANOR OF SULLIVAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VICTORIAN MANOR OF SULLIVAN
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:
VICTORIAN MANOR OF OAK GROVE/SULLIVAN
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:
1407099500
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1015 SPRINGFIELD RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OWENSVILLE
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65066
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-437-2103
Provider Business Mailing Address Fax Number:
573-437-2219

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1250 EAST SPRINGFIELD RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SULLIVAN
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63080
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-437-2103
Provider Business Practice Location Address Fax Number:
573-437-2219
Provider Enumeration Date:
04/20/2009

Additional Information

Authorized Official

Authorized Official Last Name:
QUICK
Authorized Official First Name:
NANCY
Authorized Official Middle Name:
Authorized Official Title or Position:
SECRETARY
Authorized Official Telephone Number:
573-437-2103

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  26324D , 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)





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