=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225924764
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | POTOSI SNF OPERATIONS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2025
-----------------------------------------------------
Last Update Date | 06/12/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 GEORGIAN GARDENS DR
-----------------------------------------------------
City | POTOSI
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63664-1436
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-999-2911
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2825 E COTTONWOOD PKWY STE 500
-----------------------------------------------------
City | SALT LAKE CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84121-7060
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | BRIAN RAMOS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 573-999-2911
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------