MEDICARE: CLINTON GRAN VILLA LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility		MO

General Provider Information

NPI Number	:	1023283850
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLINTON GRAN VILLA LLC

Provider Business Mailing Address
First Line	:	509 W ROGERS ST
Second Line	:
City	:	CLINTON
State	:	MO
Zip	:	64735-2548
Country	:	US
Telephone Number	:	660-885-9770
Fax Number	:

Provider Business Practice Location Address
First Line	:	509 W ROGERS ST
Second Line	:
City	:	CLINTON
State	:	MO
Zip	:	64735-2548
Country	:	US
Telephone Number	:	660-885-9770
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	KYLE TIMOTHY SCHADE
Credential	:
Telephone Number	:	573-471-1113

Provider Enumeration Date	:	04/23/2008
Last Update Date	:	02/05/2026

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Directions to “CLINTON GRAN VILLA LLC ” Practice Location

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