Healthcare Provider Details

I. General information

NPI: 1881626836
Provider Name (Legal Business Name): VAN BUREN NO1 INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 01/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 WATERCRESS ROAD
VAN BUREN MO
63965-0969
US

IV. Provider business mailing address

PO BOX 1210
SIKESTON MO
63801-1210
US

V. Phone/Fax

Practice location:
  • Phone: 573-323-4282
  • Fax: 573-323-8224
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number043397
License Number StateMO

VIII. Authorized Official

Name: CLIFF SHIRRELL
Title or Position: CORPORATE SECRETARY
Credential:
Phone: 573-471-1276