Basic Information
| Provider Information | |||||||||
| NPI: | 1770578536 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HERITAGE PARK SKILLED CARE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 MCCUTCHEN RD | ||||||||
| Address2: | |||||||||
| City: | ROLLA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 654012615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733642311 | ||||||||
| FaxNumber: | 5733242748 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 MCCUTCHEN RD | ||||||||
| Address2: | |||||||||
| City: | ROLLA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 654012615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733642311 | ||||||||
| FaxNumber: | 5733242748 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | WILLIAMS | ||||||||
| AuthorizedOfficialFirstName: | TERESA | ||||||||
| AuthorizedOfficialMiddleName: | K. | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5733642311 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 031573 | MO | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.