Basic Information
| Provider Information | |||||||||
| NPI: | 1366495384 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MISSOURI HOME CARE OF ROLLA, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CENTERWELL HOME HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6330 SPRINT PKWY STE 300 | ||||||||
| Address2: | |||||||||
| City: | OVERLAND PARK | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662111157 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9138142716 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1206 HOMELIFE PLZ | ||||||||
| Address2: | |||||||||
| City: | ROLLA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 654012512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733413456 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 09/01/2022 | ||||||||
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| AuthorizedOfficialLastName: | SKAGGS | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 9138142716 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 652-13HH | MO | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 581679602 | 05 | MO | MEDICAID |