=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891979126
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PREMIER RESIDENTIAL CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/21/2007
-----------------------------------------------------
Last Update Date | 12/21/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 109 E CROWDER ROAD
-----------------------------------------------------
City | TRENTON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64683
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 660-359-4292
-----------------------------------------------------
Fax | 660-359-3998
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 109 E CROWDER ROAD
-----------------------------------------------------
City | TRENTON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64683
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 660-359-4292
-----------------------------------------------------
Fax | 660-359-3998
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/MANAGER
-----------------------------------------------------
Name | MRS. PAULINE S GUNTER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 417-257-4217
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | 034624
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------