=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750431052
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ST LUKES CARE CENTER, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1220 E FAIRVIEW AVE
-----------------------------------------------------
City | CARTHAGE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64836-3122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-358-9084
-----------------------------------------------------
Fax | 417-358-6991
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1220 E FAIRVIEW AVE
-----------------------------------------------------
City | CARTHAGE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64836-3122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-358-9084
-----------------------------------------------------
Fax | 417-358-6991
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | SUE JOSLEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 417-358-9084
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | 031499
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------