1568821965 NPI number — PETTIS COUNTY ASSISTED LIVING, L.L.C.

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 1568821965 NPI number — PETTIS COUNTY ASSISTED LIVING, L.L.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PETTIS COUNTY ASSISTED LIVING, L.L.C.
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:
1568821965
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/15/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1869 CRAIG PARK CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63146-4122
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-543-3800
Provider Business Mailing Address Fax Number:
314-543-3880

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3017 BROOKING PARK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEDALIA
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65301-9327
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
660-827-3222
Provider Business Practice Location Address Fax Number:
660-829-2217
Provider Enumeration Date:
02/15/2016

Additional Information

Authorized Official

Authorized Official Last Name:
DESTEFANE
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
314-543-3800

Provider Taxonomy Codes

  • Taxonomy code: 310400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3104A0625X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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