Provider Demographics
NPI:1497957062
Name:MY PLACE RESIDENTIAL CARE
Entity Type:Organization
Organization Name:MY PLACE RESIDENTIAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:L
Authorized Official - Last Name:CASEY
Authorized Official - Suffix:
Authorized Official - Credentials:LPN, LNHA
Authorized Official - Phone:636-933-1793
Mailing Address - Street 1:23 N 6TH ST
Mailing Address - Street 2:
Mailing Address - City:FESTUS
Mailing Address - State:MO
Mailing Address - Zip Code:63028-1301
Mailing Address - Country:US
Mailing Address - Phone:636-933-1793
Mailing Address - Fax:636-933-6446
Practice Address - Street 1:23 N 6TH ST
Practice Address - Street 2:
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028-1301
Practice Address - Country:US
Practice Address - Phone:636-933-1793
Practice Address - Fax:636-933-6446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO033990311Z00000X
MO032831311Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO032831OtherDHSS