1619163235 NPI number — MEADOWBROOK RESIDENTIAL CARE

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 1619163235 NPI number — MEADOWBROOK RESIDENTIAL CARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEADOWBROOK RESIDENTIAL CARE
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:
Provider Other Organization Name Type Code:
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:
1619163235
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/18/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
806 W. MULBERRY STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PILOT KNOB
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63663-0510
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-546-7065
Provider Business Mailing Address Fax Number:
573-546-6355

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
806 W. MULBERRY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PILOT KNOB
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63663-0510
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-546-7065
Provider Business Practice Location Address Fax Number:
573-546-6355
Provider Enumeration Date:
09/18/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
JACKSON
Authorized Official First Name:
TONNIE
Authorized Official Middle Name:
DEAN
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
573-546-7065

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  032309 , 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)