Provider Demographics
NPI:1326205253
Name:ELDERCARE OF MID-MISSOURI V, INC.
Entity Type:Organization
Organization Name:ELDERCARE OF MID-MISSOURI V, INC.
Other - Org Name:STONEBRIDGE LAKE OZARK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY-TREASURER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:LIERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-477-3280
Mailing Address - Street 1:2500 S OLD HIGHWAY 94
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63303-5616
Mailing Address - Country:US
Mailing Address - Phone:636-477-3280
Mailing Address - Fax:
Practice Address - Street 1:872 COLLEGE BLVD
Practice Address - Street 2:
Practice Address - City:OSAGE BEACH
Practice Address - State:MO
Practice Address - Zip Code:65065-8408
Practice Address - Country:US
Practice Address - Phone:573-302-0900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-19
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO108303207Medicaid
MO108303207Medicaid