Provider Demographics
NPI:1174827166
Name:N & R OF KIMBERLING CITY LLC
Entity Type:Organization
Organization Name:N & R OF KIMBERLING CITY LLC
Other - Org Name:TABLEROCK HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:C
Authorized Official - Last Name:LINCOLN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-481-9625
Mailing Address - Street 1:276 FOUNTAIN LN
Mailing Address - Street 2:
Mailing Address - City:KIMBERLING CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65686-9356
Mailing Address - Country:US
Mailing Address - Phone:417-739-2481
Mailing Address - Fax:417-739-4412
Practice Address - Street 1:276 FOUNTAIN LN
Practice Address - Street 2:
Practice Address - City:KIMBERLING CITY
Practice Address - State:MO
Practice Address - Zip Code:65686-9356
Practice Address - Country:US
Practice Address - Phone:417-739-2481
Practice Address - Fax:417-739-4412
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-05
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO102120607Medicaid
MO102120607Medicaid