Basic Information
Provider Information | |||||||||
NPI: | 1932273331 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PALLADIAN SENIOR CARE OF POPLAR BLUFF LLC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | OAKDALE CARE CENTER RCF | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 500 NW PLAZA DR STE 712 | ||||||||
Address2: |   | ||||||||
City: | SAINT ANN | ||||||||
State: | MO | ||||||||
PostalCode: | 630742222 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3143172003 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2704 DEBBIE LN | ||||||||
Address2: |   | ||||||||
City: | POPLAR BLUFF | ||||||||
State: | MO | ||||||||
PostalCode: | 639012650 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5736865242 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/17/2006 | ||||||||
LastUpdateDate: | 06/04/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MILLS | ||||||||
AuthorizedOfficialFirstName: | MICHAEL | ||||||||
AuthorizedOfficialMiddleName: | JASON | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 3143172003 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/04/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3104A0625X | 031624 | MO | Y |   | Nursing & Custodial Care Facilities | Assisted Living Facility | Assisted Living, Mental Illness |
ID Information
ID | Type | State | Issuer | Description | 266774124 | 05 | MO |   | MEDICAID |