Healthcare Provider Details

I. General information

NPI: 1790805018
Provider Name (Legal Business Name): MIDWEST HEALTH CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 08/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2350 KANELL BLVD
POPLAR BLUFF MO
63901-4036
US

IV. Provider business mailing address

2350 KANELL BLVD
POPLAR BLUFF MO
63901-4036
US

V. Phone/Fax

Practice location:
  • Phone: 573-785-0188
  • Fax: 573-785-7321
Mailing address:
  • Phone: 573-785-0188
  • Fax: 573-785-7321

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number031347
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number037135
License Number StateMO

VIII. Authorized Official

Name: MR. JIFI JACOB
Title or Position: MANAGER
Credential:
Phone: 618-628-7671