1548296304 NPI number — PREFERRED HOSPICE OF MISSOURI LLC

Table of content: (NPI 1871132464)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548296304 NPI number — PREFERRED HOSPICE OF MISSOURI LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREFERRED HOSPICE OF MISSOURI LLC
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:
6
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:
1548296304
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/05/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1220 NORTH MAIN STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SIKESTON
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63801-4827
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-481-9625
Provider Business Mailing Address Fax Number:
573-481-9639

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
423 BUSINESS HIGHWAY 60 WEST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DEXTER
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63841-1121
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-614-4774
Provider Business Practice Location Address Fax Number:
573-614-4775
Provider Enumeration Date:
06/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LINCOLN
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
C
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
573-481-9625

Provider Taxonomy Codes

  • Taxonomy code: 251G00000X , with the licence number:  139-HO , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251G00000X , with the licence number: 139-3HO , 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: 200884 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 826195208 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1548296304 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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