Healthcare Provider Details

I. General information

NPI: 1366495384
Provider Name (Legal Business Name): MISSOURI HOME CARE OF ROLLA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 11/30/2023
Certification Date: 11/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1206 HOMELIFE PLZ
ROLLA MO
65401-2512
US

IV. Provider business mailing address

6330 SPRINT PKWY STE 300
OVERLAND PARK KS
66211-1157
US

V. Phone/Fax

Practice location:
  • Phone: 573-341-3456
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number652-13HH
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier581679602
Identifier TypeMEDICAID
Identifier StateMO
Identifier Issuer

VIII. Authorized Official

Name: JOHN NICHOLS
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 573-341-3456