MEDICARE: BRISTOL CARE, INC.

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	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1215143854
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRISTOL CARE, INC.

Provider Business Mailing Address
First Line	:	201 W 3RD ST
Second Line	:
City	:	SEDALIA
State	:	MO
Zip	:	65301-4352
Country	:	US
Telephone Number	:	660-826-0200
Fax Number	:	660-827-2027

Provider Business Practice Location Address
First Line	:	1016 E 10TH ST
Second Line	:
City	:	CARROLLTON
State	:	MO
Zip	:	64633-9348
Country	:	US
Telephone Number	:	660-542-2349
Fax Number	:	660-542-2349

Authorized Official
Title or Position	:	MEDICAID BILLING DEPARTMENT
Name	:	SHELLEY DEANNE EBELING
Credential	:
Telephone Number	:	660-826-0200

Provider Enumeration Date	:	05/14/2007
Last Update Date	:	10/02/2007

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