MEDICARE: AMERICARE AT SOUTHBROOK NURSING CENTER, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility

General Provider Information

NPI Number	:	1003190356
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AMERICARE AT SOUTHBROOK NURSING CENTER, LLC

Provider Business Mailing Address
First Line	:	1108 W LIBERTY ST
Second Line	:
City	:	FARMINGTON
State	:	MO
Zip	:	63640-1922
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1108 W LIBERTY ST
Second Line	:
City	:	FARMINGTON
State	:	MO
Zip	:	63640-1922
Country	:	US
Telephone Number	:	573-756-6658
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JAMES REIKER
Credential	:
Telephone Number	:	573-756-6658

Provider Enumeration Date	:	10/05/2011
Last Update Date	:	01/11/2012

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