Basic Information
| Provider Information | |||||||||
| NPI: | 1285930149 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | REGIONAL CARE OF HERMITAGE, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | CHRISTIAN HEALTH AND REHABILITATION OF HERMITAGE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | HWY 54 & 1ST STREET | ||||||||
| Address2: | |||||||||
| City: | HERMITAGE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 656680325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4177452111 | ||||||||
| FaxNumber: | 4177452211 | ||||||||
| Practice Location | |||||||||
| Address1: | HWY 54 & 1ST STREET | ||||||||
| Address2: | |||||||||
| City: | HERMITAGE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 656680325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4177452111 | ||||||||
| FaxNumber: | 4177452211 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2011 | ||||||||
| LastUpdateDate: | 11/07/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | LONG | ||||||||
| AuthorizedOfficialFirstName: | PHILLIP | ||||||||
| AuthorizedOfficialMiddleName: | CODY | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4794640200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 037108 | MO | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.