Basic Information
| Provider Information | |||||||||
| NPI: | 1699803973 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PCRMC-HEALTH SERVICES, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | PHELPS HEALTH HOMECARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1500 E STATE HWY 72 | ||||||||
| Address2: | |||||||||
| City: | ROLLA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 654013926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733642425 | ||||||||
| FaxNumber: | 5733643993 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 E STATE HWY 72 | ||||||||
| Address2: | |||||||||
| City: | ROLLA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 654013926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733642425 | ||||||||
| FaxNumber: | 5733643993 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2007 | ||||||||
| LastUpdateDate: | 11/10/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COOK | ||||||||
| AuthorizedOfficialFirstName: | JANA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP, CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5734587916 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 372500000X | 0004588 | MO | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Related Providers | Chore Provider | 372600000X | 0004588 | MO | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Related Providers | Adult Companion | 376J00000X | 0004588 | MO | Y | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Related Providers | Homemaker |
ID Information
| ID | Type | State | Issuer | Description | 283815504 | 05 | MO | MEDICAID |