Healthcare Provider Details

I. General information

NPI: 1205168523
Provider Name (Legal Business Name): NIRMAL K SAMANTA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2010
Last Update Date: 02/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 BRANDY LN
CAPE GIRARDEAU MO
63701-8443
US

IV. Provider business mailing address

250 BRANDY LN
CAPE GIRARDEAU MO
63701-8443
US

V. Phone/Fax

Practice location:
  • Phone: 573-450-3393
  • Fax: 573-339-0911
Mailing address:
  • Phone: 573-450-3393
  • Fax: 573-339-0911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License Number2004016682
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number2004016682
License Number StateMO

VIII. Authorized Official

Name: NIRMAL KUMAR SAMANTA
Title or Position: SPEECH -LANGUAGE PATHOLOGIST
Credential: PHD,CCC-SLP
Phone: 573-450-3393