Healthcare Provider Details

I. General information

NPI: 1043336738
Provider Name (Legal Business Name): BLUE RIVER REHABILITATION CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 01/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10425 CHESTNUT DR
KANSAS CITY MO
64137-3201
US

IV. Provider business mailing address

10425 CHESTNUT DR
KANSAS CITY MO
64137-3201
US

V. Phone/Fax

Practice location:
  • Phone: 816-763-4444
  • Fax: 816-763-4777
Mailing address:
  • Phone: 816-763-4444
  • Fax: 816-763-4777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number042936
License Number StateMO

VIII. Authorized Official

Name: MICHAEL T. BERG
Title or Position: ASSISTANT SECRETARY
Credential:
Phone: 505-468-4752