Healthcare Provider Details

I. General information

NPI: 1174476881
Provider Name (Legal Business Name): STILL WATERS SENIOR CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2026
Last Update Date: 09/18/2026
Certification Date: 02/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

335 BROOKSTONE DR
HOLTS SUMMIT MO
65043
US

IV. Provider business mailing address

2500 MISSOURI BLVD # 1002
JEFFERSON CITY MO
65109-4704
US

V. Phone/Fax

Practice location:
  • Phone: 573-203-5026
  • Fax:
Mailing address:
  • Phone: 573-203-5026
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: LAMAJAH MASEY JOHNSON
Title or Position: OWNER
Credential:
Phone: 573-203-5026