Healthcare Provider Details

I. General information

NPI: 1770528986
Provider Name (Legal Business Name): MISSION LAKE CONVALESCENT CENTER INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 02/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12110 HOLMES RD
KANSAS CITY MO
64145-1707
US

IV. Provider business mailing address

12110 HOLMES RD
KANSAS CITY MO
64145-1707
US

V. Phone/Fax

Practice location:
  • Phone: 816-941-3006
  • Fax: 816-942-8049
Mailing address:
  • Phone: 816-941-3006
  • Fax: 816-942-8049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number034738
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code332BN1400X
TaxonomyNursing Facility Supplies (DME)
License Number032111
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number032111
License Number StateMO

VIII. Authorized Official

Name: MR. LOREN REA
Title or Position: PRESIDENT
Credential:
Phone: 816-941-3006