Basic Information
Provider Information
NPI: 1669433629
EntityType: 2
ReplacementNPI:  
OrganizationName: QUAIL CREEK SKILLED NURSING, LLC
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: THE NEIGHBORHOODS AT QUAIL CREEK
OtherOrganizationType: 3
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1514 WEST LARK
Address2:  
City: SPRINGFIELD
State: MO
PostalCode: 65810
CountryCode: US
TelephoneNumber: 4178891275
FaxNumber: 4178810657
Practice Location
Address1: 1514 WEST LARK
Address2:  
City: SPRINGFIELD
State: MO
PostalCode: 65810
CountryCode: US
TelephoneNumber: 4178891275
FaxNumber: 4178810657
Other Information
ProviderEnumerationDate: 03/30/2006
LastUpdateDate: 02/01/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: REIKER
AuthorizedOfficialFirstName: JAMES
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: TREASURER
AuthorizedOfficialTelephone: 4178891275
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
314000000X032174MOY Nursing & Custodial Care FacilitiesSkilled Nursing Facility 

ID Information
IDTypeStateIssuerDescription
10267900805MO MEDICAID


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