Basic Information
| Provider Information | |||||||||
| NPI: | 1386079622 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HARRISONVILLE SENIOR CARE LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MEADOW VIEW OF HARRISONVILLE HEALTH & REHABILITATION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 920 RIDGEBROOK RD | ||||||||
| Address2: | |||||||||
| City: | SPARKS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211529390 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107731000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2203 E MECHANIC ST | ||||||||
| Address2: | |||||||||
| City: | HARRISONVILLE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 647012060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8163802622 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2013 | ||||||||
| LastUpdateDate: | 05/16/2014 | ||||||||
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| AuthorizedOfficialLastName: | MCGAVOCK | ||||||||
| AuthorizedOfficialFirstName: | KAM | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4107731000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 101481307 | 05 | MO | MEDICAID |