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General NPI Number Information
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NPI Number | 1811929623
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Entity Type | Organization
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Legal Business Name | OLIVE MOUNTAIN RESIDENTIAL CARE LLC
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Dates
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Enumeration Date | 07/06/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 25466 N HWY 5
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City | LEBANON
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State | MO
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Zip | 65536-0969
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Country | US
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Telephone | 417-532-3045
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Fax | 417-532-4104
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Provider Business Mailing Address
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Address Line | PO BOX 969
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City | LEBANON
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State | MO
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Zip | 65536-0969
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Country | US
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Telephone | 417-532-3045
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Fax | 417-532-4104
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Authorized Official
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Title or Position | FINANCIAL MANAGER
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Name | MISS STEPHANIE NICHOLE UPTON
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Credential |
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Telephone | 417-532-3045
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | 033209
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License Number State | MO
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