Provider Demographics
NPI:1134320252
Name:DEACONESS LONG TERM CARE OF MISSOURI, INC
Entity Type:Organization
Organization Name:DEACONESS LONG TERM CARE OF MISSOURI, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:513-487-3600
Mailing Address - Street 1:440 LAFAYETTE AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45220-1022
Mailing Address - Country:US
Mailing Address - Phone:513-487-3600
Mailing Address - Fax:513-487-3613
Practice Address - Street 1:440 LAFAYETTE AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45220-1022
Practice Address - Country:US
Practice Address - Phone:513-487-3600
Practice Address - Fax:513-487-3613
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
1043580001Medicare NSC