Healthcare Provider Details

I. General information

NPI: 1104982545
Provider Name (Legal Business Name): CEDAR KNOLL HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13635 STATE ROUTE V
SAINT JAMES MO
65559-8331
US

IV. Provider business mailing address

13635 STATE ROUTE V
SAINT JAMES MO
65559-8331
US

V. Phone/Fax

Practice location:
  • Phone: 573-265-3658
  • Fax: 573-265-3658
Mailing address:
  • Phone: 573-265-3658
  • Fax: 573-265-3658

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: MS. SUSAN STAPLES
Title or Position: ADMINISTRATOR
Credential:
Phone: 573-265-3658