Healthcare Provider Details

I. General information

NPI: 1215928130
Provider Name (Legal Business Name): KNOX COUNTY NURSING HOME DISTRICT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RR 3 BOX 53
EDINA MO
63537-9677
US

IV. Provider business mailing address

RR 3 BOX 53
EDINA MO
63537-9677
US

V. Phone/Fax

Practice location:
  • Phone: 660-397-2282
  • Fax: 660-397-2284
Mailing address:
  • Phone: 660-397-2282
  • Fax: 660-397-2284

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number030962
License Number StateMO

VIII. Authorized Official

Name: TIM SCHRAGE
Title or Position: ADMINISTRATOR
Credential:
Phone: 660-397-2282