Healthcare Provider Details

I. General information

NPI: 1912424607
Provider Name (Legal Business Name): LICKING NO 1 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2017
Last Update Date: 08/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 HICKORY ST
LICKING MO
65542
US

IV. Provider business mailing address

731 N MAIN ST
SIKESTON MO
63801-2151
US

V. Phone/Fax

Practice location:
  • Phone: 573-674-2111
  • Fax:
Mailing address:
  • Phone: 573-471-1276
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number046854
License Number StateMO

VIII. Authorized Official

Name: MR. DONALD B BEDELL
Title or Position: PRESIDENT
Credential:
Phone: 573-471-1276