Healthcare Provider Details

I. General information

NPI: 1043291255
Provider Name (Legal Business Name): PEARL'S II EDEN FOR ELDERS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2005
Last Update Date: 03/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 N COLLEGE AVE
PRINCETON MO
64673-1051
US

IV. Provider business mailing address

611 N COLLEGE AVE
PRINCETON MO
64673-1051
US

V. Phone/Fax

Practice location:
  • Phone: 660-748-4407
  • Fax: 660-748-4409
Mailing address:
  • Phone: 660-748-4407
  • Fax: 660-748-4409

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number031116
License Number StateMO

VIII. Authorized Official

Name: MRS. JUDY CHERYLE BAGLEY
Title or Position: ADMINISTRATOR
Credential:
Phone: 660-748-4407