Healthcare Provider Details

I. General information

NPI: 1568821965
Provider Name (Legal Business Name): PETTIS COUNTY ASSISTED LIVING, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2016
Last Update Date: 02/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3017 BROOKING PARK AVE
SEDALIA MO
65301-9327
US

IV. Provider business mailing address

1869 CRAIG PARK CT
SAINT LOUIS MO
63146-4122
US

V. Phone/Fax

Practice location:
  • Phone: 660-827-3222
  • Fax: 660-829-2217
Mailing address:
  • Phone: 314-543-3800
  • Fax: 314-543-3880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State

VIII. Authorized Official

Name: MR. RICHARD J DESTEFANE
Title or Position: PRESIDENT
Credential:
Phone: 314-543-3800