Provider Demographics
NPI: | 1376893297 |
---|---|
Name: | RELIANT CARE REHABILITATIVE SERVICES |
Entity Type: | Organization |
Organization Name: | RELIANT CARE REHABILITATIVE SERVICES |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | LPTA |
Authorized Official - Prefix: | MRS |
Authorized Official - First Name: | MARY |
Authorized Official - Middle Name: | SUSAN |
Authorized Official - Last Name: | PERNELL |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | LPTA |
Authorized Official - Phone: | 314-524-6191 |
Mailing Address - Street 1: | 411 ROBERT AVE |
Mailing Address - Street 2: | |
Mailing Address - City: | FERGUSON |
Mailing Address - State: | MO |
Mailing Address - Zip Code: | 63135-3526 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 314-524-6191 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 411 ROBERT AVE |
Practice Address - Street 2: | |
Practice Address - City: | FERGUSON |
Practice Address - State: | MO |
Practice Address - Zip Code: | 63135-3526 |
Practice Address - Country: | US |
Practice Address - Phone: | 314-524-6191 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2012-09-18 |
Last Update Date: | 2012-09-18 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MO | 116138 | 313M00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 313M00000X | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |