Healthcare Provider Details

I. General information

NPI: 1801038724
Provider Name (Legal Business Name): PACIFIC CARE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2009
Last Update Date: 10/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 SOUTH SIXTH STREET
PACIFIC MO
63069
US

IV. Provider business mailing address

105 SOUTH SIXTH STREET
PACIFIC MO
63069
US

V. Phone/Fax

Practice location:
  • Phone: 636-271-4222
  • Fax: 636-257-8002
Mailing address:
  • Phone: 636-271-4222
  • Fax: 636-257-8002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number036467
License Number StateMO

VIII. Authorized Official

Name: MRS. GRETCHEN R ROBERTS-HOAGLIN
Title or Position: ADMINISTRATOR
Credential: R.N. LICENSED NURSIN
Phone: 636-271-4222