MEDICARE: MISSION LAKE CONVALESCENT CENTER 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	332BN1400X	Nursing Facility Supplies (DME)	032111	MO
2	332BP3500X	Parenteral & Enteral Nutrition Supplies (DME)	032111	MO
3	314000000X	Skilled Nursing Facility	034738	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	032111	OTHER	MO	PROVIDER
2	1770528986	OTHER	MO	NPI
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1770528986
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MISSION LAKE CONVALESCENT CENTER INC.

Provider Business Mailing Address
First Line	:	12110 HOLMES RD
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64145-1707
Country	:	US
Telephone Number	:	816-941-3006
Fax Number	:	816-942-8049

Provider Business Practice Location Address
First Line	:	12110 HOLMES RD
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64145-1707
Country	:	US
Telephone Number	:	816-941-3006
Fax Number	:	816-942-8049

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. LOREN REA
Credential	:
Telephone Number	:	816-941-3006

Provider Enumeration Date	:	06/19/2006
Last Update Date	:	02/19/2013

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