Healthcare Provider Details

I. General information

NPI: 1669404638
Provider Name (Legal Business Name): MOUNTAIN GROVE 2 INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 04/30/2021
Certification Date: 04/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 N HOVIS ST
MOUNTAIN GROVE MO
65711-1219
US

IV. Provider business mailing address

731 N MAIN ST PO BOX 1210
SIKESTON MO
63801-2151
US

V. Phone/Fax

Practice location:
  • Phone: 417-926-5128
  • 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 Number044753
License Number StateMO

VIII. Authorized Official

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