Healthcare Provider Details

I. General information

NPI: 1881249464
Provider Name (Legal Business Name): ROLLA GRAND LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2019
Last Update Date: 08/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 WHITE COLUMNS DR
ROLLA MO
65401-2044
US

IV. Provider business mailing address

1749 GILSINN LN
FENTON MO
63026-2008
US

V. Phone/Fax

Practice location:
  • Phone: 314-267-3725
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name: GREG SPENCE
Title or Position: OWNER
Credential:
Phone: 636-349-2311