MEDICARE: ROLLA RESIDENTIAL, 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	310400000X	Assisted Living Facility

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

General Provider Information

NPI Number	:	1972559276
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROLLA RESIDENTIAL, LLC

Provider Business Mailing Address
First Line	:	2100 PARKSIDE AVE
Second Line	:
City	:	ROLLA
State	:	MO
Zip	:	65401-5472
Country	:	US
Telephone Number	:	573-308-0384
Fax Number	:	573-308-1644

Provider Business Practice Location Address
First Line	:	2100 PARKSIDE AVE
Second Line	:
City	:	ROLLA
State	:	MO
Zip	:	65401-5472
Country	:	US
Telephone Number	:	573-308-0384
Fax Number	:	573-308-1644

Authorized Official
Title or Position	:	MANAGER
Name	:	KYLE TIMOTHY SCHADE
Credential	:
Telephone Number	:	573-471-1113

Provider Enumeration Date	:	05/26/2006
Last Update Date	:	02/02/2026

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Directions to “ROLLA RESIDENTIAL, LLC ” Practice Location

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