Healthcare Provider Details

I. General information

NPI: 1558359760
Provider Name (Legal Business Name): PALLADIAN SENIOR CARE OF POPLAR BLUFF LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 03/18/2024
Certification Date: 03/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2702 DEBBIE LN
POPLAR BLUFF MO
63901-2650
US

IV. Provider business mailing address

500 NW PLAZA DR STE 712
SAINT ANN MO
63074-2222
US

V. Phone/Fax

Practice location:
  • Phone: 573-686-5242
  • Fax: 573-686-3637
Mailing address:
  • Phone: 314-566-0459
  • Fax: 573-686-3637

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number031709
License Number StateMO

VIII. Authorized Official

Name: MR. MICHAEL JASON MILLS
Title or Position: CFO
Credential:
Phone: 314-317-2003