Healthcare Provider Details

I. General information

NPI: 1982901609
Provider Name (Legal Business Name): ELDERCARE OF MID-MISSOURI X, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2011
Last Update Date: 12/01/2020
Certification Date: 12/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1024 ADAMS ST
JEFFERSON CITY MO
65101-3408
US

IV. Provider business mailing address

1024 ADAMS ST
JEFFERSON CITY MO
65101-3408
US

V. Phone/Fax

Practice location:
  • Phone: 573-635-1320
  • Fax: 573-634-3944
Mailing address:
  • Phone: 636-477-3280
  • Fax: 636-477-3241

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. MARK LIERMAN
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 636-477-3280