Provider Demographics
NPI:1508311747
Name:N & R OF MARYVILLE LLC
Entity Type:Organization
Organization Name:N & R OF MARYVILLE LLC
Other - Org Name:MARYVILLE LIVING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MATHIAS
Authorized Official - Middle Name:P
Authorized Official - Last Name:DASAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-481-9625
Mailing Address - Street 1:524 N LAURA ST
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64468-1955
Mailing Address - Country:US
Mailing Address - Phone:660-582-7447
Mailing Address - Fax:660-582-4027
Practice Address - Street 1:524 N LAURA ST
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:MO
Practice Address - Zip Code:64468-1955
Practice Address - Country:US
Practice Address - Phone:660-582-7447
Practice Address - Fax:660-582-4027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-17
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO043410314000000X
MO042102320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO101490902Medicaid
CA265354Medicare Oscar/Certification