1598819112 NPI number — CATHEDRAL ROCK OF ROLLA INC

Table of content: CASSIUS A. SCOTT MD (NPI 1205910379)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598819112 NPI number — CATHEDRAL ROCK OF ROLLA INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CATHEDRAL ROCK OF ROLLA 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:
HERITAGE PARK SKILLED CARE
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:
1598819112
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/02/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
306 W 7TH ST STE 415
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76102-4905
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-335-4111
Provider Business Mailing Address Fax Number:
817-335-0800

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1200 MCCUTCHEN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROLLA
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65401-2615
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-364-2311
Provider Business Practice Location Address Fax Number:
573-364-2748
Provider Enumeration Date:
01/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HARRINGTON
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
KENT
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
817-335-4111

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  032162 , 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: 101475408 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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