Healthcare Provider Details

I. General information

NPI: 1699803999
Provider Name (Legal Business Name): FOUR SEASONS LIVING CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 HIGHWAY TT
SEDALIA MO
65301-1410
US

IV. Provider business mailing address

2800 HIGHWAY TT
SEDALIA MO
65301-1410
US

V. Phone/Fax

Practice location:
  • Phone: 660-826-8803
  • Fax: 660-826-6864
Mailing address:
  • Phone: 660-826-8803
  • Fax: 660-826-6864

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