Basic Information
| Provider Information | |||||||||
| NPI: | 1740273176 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DEACONESS LONG TERM CARE OF MISSOURI, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | COUNTRY AIRE RETIREMENT ESTATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 440 LAFAYETTE AVE | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452201022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5134873600 | ||||||||
| FaxNumber: | 5134873653 | ||||||||
| Practice Location | |||||||||
| Address1: | 18540 STATE HIGHWAY 16 | ||||||||
| Address2: | |||||||||
| City: | LEWISTOWN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 634522111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5732152216 | ||||||||
| FaxNumber: | 5732152733 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2005 | ||||||||
| LastUpdateDate: | 10/07/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BROOKS | ||||||||
| AuthorizedOfficialFirstName: | CARLA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5134873600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 029664 | MO | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 103108304 | 05 | MO | MEDICAID | 5733217 | 01 | MO | AETNA | OTHER |