=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255736518
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CEDAR RIDGE CARE CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/29/2014
-----------------------------------------------------
Last Update Date | 10/29/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 71 SYCAMORE ST
-----------------------------------------------------
City | CASSVILLE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65625-1755
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-847-5546
-----------------------------------------------------
Fax | 417-847-8826
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 71 SYCAMORE ST P.O. BOX 633
-----------------------------------------------------
City | CASSVILLE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65625-1755
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-847-5546
-----------------------------------------------------
Fax | 417-847-8826
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MARY HOWLETT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 573-855-9088
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | 040818
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------