MEDICARE: DEACONESS LONG TERM CARE OF MISSOURI, 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	314000000X	Skilled Nursing Facility	029219	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	90483-010	OTHER	MO	BLUE CROSS
3	90483-010	OTHER	MO	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1558355909
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEACONESS LONG TERM CARE OF MISSOURI, INC.

Provider Business Mailing Address
First Line	:	440 LAFAYETTE AVE
Second Line	:	SUITE 400
City	:	CINCINNATI
State	:	OH
Zip	:	45220-1022
Country	:	US
Telephone Number	:	513-487-3600
Fax Number	:	513-487-3653

Provider Business Practice Location Address
First Line	:	2323 SWOPE PKWY
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64130-2638
Country	:	US
Telephone Number	:	816-924-1122
Fax Number	:	816-923-0955

Authorized Official
Title or Position	:	CFO
Name	:	CARLA BROOKS
Credential	:
Telephone Number	:	513-487-3600

Provider Enumeration Date	:	08/31/2005
Last Update Date	:	10/02/2008

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