Basic Information
Provider Information | |||||||||
NPI: | 1417255456 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BENCHMARK HEALTHCARE OF LOMA LINDA 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: | 6364491794 | ||||||||
FaxNumber: | 6365364533 | ||||||||
Practice Location | |||||||||
Address1: | 1600 E ROLLINS ST | ||||||||
Address2: |   | ||||||||
City: | MOBERLY | ||||||||
State: | MO | ||||||||
PostalCode: | 652702478 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6602636887 | ||||||||
FaxNumber: | 6602638823 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/28/2011 | ||||||||
LastUpdateDate: | 11/08/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SELLS | ||||||||
AuthorizedOfficialFirstName: | JOHN | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
AuthorizedOfficialTelephone: | 6364491795 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | PENDING | MO | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 102385002 | 05 | MO |   | MEDICAID |