Provider Demographics
NPI:1003083155
Name:CHEROKEE RESIDENTIAL CARE LLC
Entity Type:Organization
Organization Name:CHEROKEE RESIDENTIAL CARE LLC
Other - Org Name:NEW HEIGHTS RESIDENTIAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:RANDAL
Authorized Official - Last Name:GETTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:314-368-3247
Mailing Address - Street 1:3409 MISSOURI AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63118
Mailing Address - Country:US
Mailing Address - Phone:314-368-3247
Mailing Address - Fax:314-771-1377
Practice Address - Street 1:3409 MISSOURI AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63118
Practice Address - Country:US
Practice Address - Phone:314-368-3247
Practice Address - Fax:314-771-1377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-08
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0345143104A0625X
MO0425863104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO266735109Medicaid