Healthcare Provider Details

I. General information

NPI: 1548399272
Provider Name (Legal Business Name): DESOTO RESIDENTIAL CARE APTS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 06/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1550 VILLA DR
DE SOTO MO
63020-2586
US

IV. Provider business mailing address

1550 VILLA DR
DE SOTO MO
63020-2586
US

V. Phone/Fax

Practice location:
  • Phone: 636-586-6559
  • Fax:
Mailing address:
  • Phone: 636-586-6559
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number031260
License Number StateMO

VIII. Authorized Official

Name: MARY R MENZ
Title or Position: BILLER
Credential:
Phone: 573-659-6607