Healthcare Provider Details

I. General information

NPI: 1063424000
Provider Name (Legal Business Name): COUNTRY MEADOWS NURSING CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 N SAINT JOE DR
PARK HILLS MO
63601-1965
US

IV. Provider business mailing address

765 WEBER RD
FARMINGTON MO
63640-3318
US

V. Phone/Fax

Practice location:
  • Phone: 573-701-0600
  • Fax: 573-701-0601
Mailing address:
  • Phone: 573-701-0600
  • Fax: 573-701-0601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number032557
License Number StateMO

VIII. Authorized Official

Name: DR. SHARO SHIRSHEKAN III
Title or Position: CEO/MANAGING MEMEBER
Credential:
Phone: 573-701-0600