Basic Information
| Provider Information | |||||||||
| NPI: | 1598819112 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CATHEDRAL ROCK OF ROLLA INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HERITAGE PARK SKILLED CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 306 W 7TH ST STE 415 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761024905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173354111 | ||||||||
| FaxNumber: | 8173350800 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 MCCUTCHEN RD | ||||||||
| Address2: | |||||||||
| City: | ROLLA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 654012615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733642311 | ||||||||
| FaxNumber: | 5733642748 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2007 | ||||||||
| LastUpdateDate: | 09/02/2008 | ||||||||
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| AuthorizedOfficialLastName: | HARRINGTON | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | KENT | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8173354111 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 032162 | MO | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 101475408 | 05 | MO | MEDICAID |