Healthcare Provider Details

I. General information

NPI: 1649453408
Provider Name (Legal Business Name): KIDWELL HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2007
Last Update Date: 12/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 KIDWELL DRIVE
VERSAILLES MO
65084
US

IV. Provider business mailing address

1101 W CLAY RD
VERSAILLES MO
65084-9314
US

V. Phone/Fax

Practice location:
  • Phone: 573-378-5411
  • Fax: 573-378-5415
Mailing address:
  • Phone: 573-378-5411
  • Fax: 573-378-5415

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number032825
License Number StateMO

VIII. Authorized Official

Name: MRS. SANDI LEONARD
Title or Position: ADMINISTRATOR
Credential:
Phone: 573-378-5411