Healthcare Provider Details

I. General information

NPI: 1518999515
Provider Name (Legal Business Name): AVA NO 1 INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 02/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HC 71 BOX 43
AVA MO
65608-8903
US

IV. Provider business mailing address

PO BOX 1210
SIKESTON MO
63801-1210
US

V. Phone/Fax

Practice location:
  • Phone: 417-638-4129
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number045990
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier101482404
Identifier TypeMEDICAID
Identifier StateMO
Identifier Issuer

VIII. Authorized Official

Name: MR. DONALD B BEDELL
Title or Position: PRESIDENT
Credential:
Phone: 573-471-1276