Healthcare Provider Details

I. General information

NPI: 1003817248
Provider Name (Legal Business Name): GOOD SAMARITAN NURSING HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 12/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 W MAIN ST
COLE CAMP MO
65325-1144
US

IV. Provider business mailing address

403 W MAIN ST
COLE CAMP MO
65325-1144
US

V. Phone/Fax

Practice location:
  • Phone: 660-668-4515
  • Fax: 660-668-4975
Mailing address:
  • Phone: 660-668-4515
  • Fax: 660-668-4975

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number029352
License Number StateMO

VIII. Authorized Official

Name: MRS. DONNA NELL STELLING
Title or Position: ADMINISTRATOR
Credential:
Phone: 660-668-4515