Provider Demographics
NPI:1508373838
Name:SUNTERRA SPRINGFIELD OC, LLC
Entity Type:Organization
Organization Name:SUNTERRA SPRINGFIELD OC, LLC
Other - Org Name:SUNTERRA SPRINGS SPRINGFIELD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:RORY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-318-6476
Mailing Address - Street 1:PO BOX 51298
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83405-1298
Mailing Address - Country:US
Mailing Address - Phone:208-523-3794
Mailing Address - Fax:
Practice Address - Street 1:4935 S NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65810
Practice Address - Country:US
Practice Address - Phone:208-523-3794
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-09
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO265871OtherMEDICARE PROVIDER NUMBER
MOFL001422355OtherSTATE OF MISSOURI REGISTRATION