Healthcare Provider Details

I. General information

NPI: 1598819112
Provider Name (Legal Business Name): CATHEDRAL ROCK OF ROLLA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 09/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 MCCUTCHEN RD
ROLLA MO
65401-2615
US

IV. Provider business mailing address

306 W 7TH ST STE 415
FORT WORTH TX
76102-4905
US

V. Phone/Fax

Practice location:
  • Phone: 573-364-2311
  • Fax: 573-364-2748
Mailing address:
  • Phone: 817-335-4111
  • Fax: 817-335-0800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number032162
License Number StateMO

VII. Legacy identifiers

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

# 1
Identifier101475408
Identifier TypeMEDICAID
Identifier StateMO
Identifier Issuer

VIII. Authorized Official

Name: CHARLES KENT HARRINGTON
Title or Position: PRESIDENT
Credential:
Phone: 817-335-4111