Basic Information
| Provider Information | |||||||||
| NPI: | 1558359760 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PALLADIAN SENIOR CARE OF POPLAR BLUFF LLC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | OAKDALE CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 NW PLAZA DR STE 712 | ||||||||
| Address2: | |||||||||
| City: | SAINT ANN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630742222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145660459 | ||||||||
| FaxNumber: | 5736863637 | ||||||||
| Practice Location | |||||||||
| Address1: | 2702 DEBBIE LN | ||||||||
| Address2: | |||||||||
| City: | POPLAR BLUFF | ||||||||
| State: | MO | ||||||||
| PostalCode: | 639012650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736865242 | ||||||||
| FaxNumber: | 5736863637 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2005 | ||||||||
| LastUpdateDate: | 06/04/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MILLS | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | JASON | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3143172003 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 031709 | MO | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 106774102 | 05 | MO | MEDICAID |