Provider Demographics
NPI:1477008779
Name:PRAIRIE VIEW SKILLED NURSING LLC
Entity Type:Organization
Organization Name:PRAIRIE VIEW SKILLED NURSING LLC
Other - Org Name:PRAIRIE VIEW SKILLED NURSING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:P
Authorized Official - Last Name:SELLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-703-3049
Mailing Address - Street 1:606 W MISSOURI ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63825-9706
Mailing Address - Country:US
Mailing Address - Phone:573-568-2137
Mailing Address - Fax:573-568-9906
Practice Address - Street 1:606 W MISSOURI ST
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:MO
Practice Address - Zip Code:63825-9706
Practice Address - Country:US
Practice Address - Phone:573-568-2137
Practice Address - Fax:573-568-9906
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-17
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO101456002Medicaid
CA265451Medicare Oscar/Certification