Healthcare Provider Details

I. General information

NPI: 1932130101
Provider Name (Legal Business Name): GENERAL BAPTIST NURSING HOME, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 07/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17108 US HIGHWAY 62
CAMPBELL MO
63933-6383
US

IV. Provider business mailing address

17108 US HIGHWAY 62
CAMPBELL MO
63933-6383
US

V. Phone/Fax

Practice location:
  • Phone: 573-246-2155
  • Fax: 573-246-2269
Mailing address:
  • Phone: 573-246-2155
  • Fax: 573-246-2269

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number030762
License Number StateMO

VII. Legacy identifiers

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

# 1
Identifier101486801
Identifier TypeMEDICAID
Identifier StateMO
Identifier Issuer

VIII. Authorized Official

Name: MR. SCOTT R COLE
Title or Position: CEO
Credential:
Phone: 870-598-1020