Basic Information
| Provider Information | |||||||||
| NPI: | 1780803221 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EMERITUSCORPORATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | AUTUMNRIDGE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3131 ELLIOTT AVE | ||||||||
| Address2: | SUITE500 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981211044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2062982909 | ||||||||
| FaxNumber: | 2063014500 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 AUTUMN RIDGE DR | ||||||||
| Address2: | |||||||||
| City: | HERCULANEUM | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630481506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6369318400 | ||||||||
| FaxNumber: | 6369333975 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BELFORD | ||||||||
| AuthorizedOfficialFirstName: | CHRIS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VPO | ||||||||
| AuthorizedOfficialTelephone: | 2148235854 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | 032614 | MO | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.