Healthcare Provider Details

I. General information

NPI: 1508311747
Provider Name (Legal Business Name): N & R OF MARYVILLE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2016
Last Update Date: 11/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

524 N LAURA ST
MARYVILLE MO
64468-1955
US

IV. Provider business mailing address

524 N LAURA ST
MARYVILLE MO
64468-1955
US

V. Phone/Fax

Practice location:
  • Phone: 660-582-7447
  • Fax: 660-582-4027
Mailing address:
  • Phone: 660-582-7447
  • Fax: 660-582-4027

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number043410
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License Number042102
License Number StateMO

VIII. Authorized Official

Name: MATHIAS P DASAL
Title or Position: MEMBER
Credential:
Phone: 573-481-9625