Healthcare Provider Details

I. General information

NPI: 1932193356
Provider Name (Legal Business Name): DEACONESS LONG TERM CARE OF MISSOURI, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 10/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 S JEFFERSON PKWY
HARRISONVILLE MO
64701-3714
US

IV. Provider business mailing address

440 LAFAYETTE AVE SUITE 400
CINCINNATI OH
45220-1022
US

V. Phone/Fax

Practice location:
  • Phone: 816-380-4731
  • Fax: 816-380-4730
Mailing address:
  • Phone: 513-487-3600
  • Fax: 513-487-3653

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number029849
License Number StateMO

VIII. Authorized Official

Name: CARLA BROOKS
Title or Position: CFO
Credential:
Phone: 513-487-3600