Provider Demographics
NPI:1275891079
Name:SUPERIOR PARK RCF, LLC
Entity Type:Organization
Organization Name:SUPERIOR PARK RCF, LLC
Other - Org Name:SUPERIOR PARK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:KAYATTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-581-7120
Mailing Address - Street 1:410 SUPERIOR ST
Mailing Address - Street 2:
Mailing Address - City:EXCELSIOR SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:64024-2456
Mailing Address - Country:US
Mailing Address - Phone:816-630-3177
Mailing Address - Fax:
Practice Address - Street 1:410 SUPERIOR ST
Practice Address - Street 2:
Practice Address - City:EXCELSIOR SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64024-2456
Practice Address - Country:US
Practice Address - Phone:816-630-3177
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-30
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO3104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness