Basic Information
| Provider Information | |||||||||
| NPI: | 1629370200 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LOMA LINDA HEALTH CARE CENTER, L.L.C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9200 WATSON RD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631261528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145433800 | ||||||||
| FaxNumber: | 3145433880 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 E ROLLINS ST | ||||||||
| Address2: | |||||||||
| City: | MOBERLY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652702478 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6602636887 | ||||||||
| FaxNumber: | 6602638823 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2010 | ||||||||
| LastUpdateDate: | 12/02/2010 | ||||||||
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| AuthorizedOfficialLastName: | DESTEFANE | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3145433800 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.