Basic Information
| Provider Information | |||||||||
| NPI: | 1457334880 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRIMROSE PLACE INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1115 E PRIMROSE ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658075146 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172699010 | ||||||||
| FaxNumber: | 4172699966 | ||||||||
| Practice Location | |||||||||
| Address1: | 1115 E PRIMROSE ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658075146 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172699010 | ||||||||
| FaxNumber: | 4172699966 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2005 | ||||||||
| LastUpdateDate: | 09/10/2009 | ||||||||
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| AuthorizedOfficialLastName: | PRENGER | ||||||||
| AuthorizedOfficialFirstName: | RON | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4172699010 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 030605 | MO | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 106915705 | 05 | MO | MEDICAID |