Healthcare Provider Details

I. General information

NPI: 1154005213
Provider Name (Legal Business Name): WEISENBORN ROAD HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2023
Last Update Date: 06/09/2023
Certification Date: 06/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1616 WEISENBORN RD
SAINT JOSEPH MO
64507-2527
US

IV. Provider business mailing address

11012 CANYON RD E STE 8
PUYALLUP WA
98373-3002
US

V. Phone/Fax

Practice location:
  • Phone: 816-232-9874
  • 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

VIII. Authorized Official

Name: WILLIAM MILLER
Title or Position: AUTHORIZED PERSON
Credential:
Phone: 253-268-2410