Healthcare Provider Details

I. General information

NPI: 1265464234
Provider Name (Legal Business Name): EXCELSIOR SPRING 1 INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 01/21/2022
Certification Date: 01/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1410 HOSPITAL DRIVE
EXCELSIOR SPRINGS MO
64024
US

IV. Provider business mailing address

PO BOX 1210 731 NORTH MAIN STREET
SIKESTON MO
63801-1210
US

V. Phone/Fax

Practice location:
  • Phone: 816-637-1010
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number046374
License Number StateMO

VII. Legacy identifiers

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

# 1
Identifier101455806
Identifier TypeMEDICAID
Identifier StateMO
Identifier Issuer

VIII. Authorized Official

Name: DONALD B BEDELL
Title or Position: PRESIDENT
Credential:
Phone: 573-471-1276