=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558355925
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DEACONESS LONG TERM CARE OF MISSOURI, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2005
-----------------------------------------------------
Last Update Date | 10/07/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 307 E SOUTH ST
-----------------------------------------------------
City | HARRISONVILLE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64701-3241
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-380-7399
-----------------------------------------------------
Fax | 816-380-6352
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 440 LAFAYETTE AVE SUITE 400
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45220-1022
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-487-3600
-----------------------------------------------------
Fax | 513-487-3653
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | CARLA BROOKS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 513-487-3600
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 029252
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------