Healthcare Provider Details

I. General information

NPI: 1619367661
Provider Name (Legal Business Name): ROCK CARE ASSISTED LIVING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2015
Last Update Date: 03/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2370 N HIGH ST SUITE NUMBER 5
JACKSON MO
63755-8365
US

IV. Provider business mailing address

2370 N HIGH ST SUITE NUMBER 5
JACKSON MO
63755-8365
US

V. Phone/Fax

Practice location:
  • Phone: 573-204-7620
  • Fax: 573-204-0222
Mailing address:
  • Phone: 573-204-7620
  • Fax: 573-204-0222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: THOMAS D WHITE
Title or Position: CEO
Credential:
Phone: 573-204-7620