Healthcare Provider Details

I. General information

NPI: 1437286028
Provider Name (Legal Business Name): CHARITON PARK HEALTH CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

902 MANOR DR
SALISBURY MO
65281-1236
US

IV. Provider business mailing address

902 MANOR DR
SALISBURY MO
65281-1236
US

V. Phone/Fax

Practice location:
  • Phone: 660-388-6486
  • Fax: 660-388-5994
Mailing address:
  • Phone: 660-388-6486
  • Fax: 660-388-5994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number
License Number State

VIII. Authorized Official

Name: RICHARD JOSEPH DESTEFANE
Title or Position: PRESIDENT
Credential:
Phone: 314-543-3800