Basic Information
| Provider Information | |||||||||
| NPI: | 1003230913 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GENERATIONS HEALTH SYSTEMS OF DEXTER, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 17826 EDISON AVE | ||||||||
| Address2: | |||||||||
| City: | CHESTERFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630051262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6365365365 | ||||||||
| FaxNumber: | 6365364533 | ||||||||
| Practice Location | |||||||||
| Address1: | 13134 STATE HIGHWAY 25 | ||||||||
| Address2: | |||||||||
| City: | DEXTER | ||||||||
| State: | MO | ||||||||
| PostalCode: | 638419740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736244433 | ||||||||
| FaxNumber: | 5736244434 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2014 | ||||||||
| LastUpdateDate: | 02/12/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SELLS | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6365365365 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LEGACY HEALTH SYSTEMS, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.