MEDICARE: MARIAN CLIFF RESIDENTIAL CARE 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	3104A0625X	Assisted Living Facility (Mental Illness)

General Provider Information

NPI Number	:	1871150755
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARIAN CLIFF RESIDENTIAL CARE CENTER, LLC

Provider Business Mailing Address
First Line	:	PO BOX 272
Second Line	:
City	:	FARMINGTON
State	:	MO
Zip	:	63640-0272
Country	:	US
Telephone Number	:	573-330-3760
Fax Number	:

Provider Business Practice Location Address
First Line	:	381 ELM ST
Second Line	:
City	:	SAINT MARY
State	:	MO
Zip	:	63673-9330
Country	:	US
Telephone Number	:	573-330-3760
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KAREN E. VEACH
Credential	:
Telephone Number	:	573-330-3760

Provider Enumeration Date	:	05/25/2019
Last Update Date	:	05/25/2019

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