Provider Demographics
NPI:1265464234
Name:EXCELSIOR SPRING 1 INC
Entity Type:Organization
Organization Name:EXCELSIOR SPRING 1 INC
Other - Org Name:VALLEY MANOR & REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:B
Authorized Official - Last Name:BEDELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-471-1276
Mailing Address - Street 1:PO BOX 1210
Mailing Address - Street 2:731 NORTH MAIN STREET
Mailing Address - City:SIKESTON
Mailing Address - State:MO
Mailing Address - Zip Code:63801-1210
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1410 HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:EXCELSIOR SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64024
Practice Address - Country:US
Practice Address - Phone:816-637-1010
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO046374314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO101455806Medicaid
MO101455806Medicaid