Healthcare Provider Details

I. General information

NPI: 1972597318
Provider Name (Legal Business Name): DEACONESS LONG TERM CARE OF MISSOURI, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 10/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 GEORGIAN GARDENS DR
POTOSI MO
63664-1436
US

IV. Provider business mailing address

440 LAFAYETTE AVE SUITE 400
CINCINNATI OH
45220-1022
US

V. Phone/Fax

Practice location:
  • Phone: 573-438-6261
  • Fax: 573-438-2807
Mailing address:
  • Phone: 513-487-3600
  • Fax: 513-487-3609

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number029171
License Number StateMO

VIII. Authorized Official

Name: CARLA BROOKS
Title or Position: CFO
Credential:
Phone: 513-487-3600