Healthcare Provider Details

I. General information

NPI: 1700061454
Provider Name (Legal Business Name): SHELBY COUNTY SENIOR CITIZENS ASSOCIATION INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/31/2007
Last Update Date: 12/31/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 E CHESTNUT ST
SHELBINA MO
63468-1339
US

IV. Provider business mailing address

112 EAST CHESTNUT
SHELBINA MO
63468-1339
US

V. Phone/Fax

Practice location:
  • Phone: 573-588-4403
  • Fax: 573-588-1406
Mailing address:
  • Phone: 573-588-4403
  • Fax: 573-588-1406

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number0000457
License Number StateMO

VIII. Authorized Official

Name: MRS. DEBRA LEA SPARKS
Title or Position: ADMINISTRATOR/MANAGER
Credential:
Phone: 573-588-4403