Provider Demographics
NPI:1184653297
Name:SPRINGFIELD RESIDENTIAL CENTER , INC.
Entity Type:Organization
Organization Name:SPRINGFIELD RESIDENTIAL CENTER , INC.
Other - Org Name:SPRINGFIELD SKILLED CARE CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:O
Authorized Official - Last Name:MATTOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-864-4545
Mailing Address - Street 1:2401 W GRAND ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65802-4967
Mailing Address - Country:US
Mailing Address - Phone:417-864-4545
Mailing Address - Fax:417-864-4768
Practice Address - Street 1:2401 W GRAND ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65802-4967
Practice Address - Country:US
Practice Address - Phone:417-864-4545
Practice Address - Fax:417-864-4768
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO102500303Medicaid
MO262500309Medicaid
MO262500309Medicaid