Provider Demographics
NPI:1386691053
Name:MEXICO RESIDENTIAL, LLC
Entity Type:Organization
Organization Name:MEXICO RESIDENTIAL, LLC
Other - Org Name:LAKEVIEW BEND
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:REIKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-471-1113
Mailing Address - Street 1:1700 ASBURY CIR W
Mailing Address - Street 2:
Mailing Address - City:MEXICO
Mailing Address - State:MO
Mailing Address - Zip Code:65265-1400
Mailing Address - Country:US
Mailing Address - Phone:573-581-8777
Mailing Address - Fax:
Practice Address - Street 1:1700 ASBURY CIR W
Practice Address - Street 2:
Practice Address - City:MEXICO
Practice Address - State:MO
Practice Address - Zip Code:65265-1400
Practice Address - Country:US
Practice Address - Phone:573-581-8777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility