Provider Demographics
NPI:1548399272
Name:DESOTO RESIDENTIAL CARE APTS, INC.
Entity Type:Organization
Organization Name:DESOTO RESIDENTIAL CARE APTS, INC.
Other - Org Name:THE VILLAS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:R
Authorized Official - Last Name:MENZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-659-6607
Mailing Address - Street 1:1550 VILLA DR
Mailing Address - Street 2:
Mailing Address - City:DE SOTO
Mailing Address - State:MO
Mailing Address - Zip Code:63020-2586
Mailing Address - Country:US
Mailing Address - Phone:636-586-6559
Mailing Address - Fax:
Practice Address - Street 1:1550 VILLA DR
Practice Address - Street 2:
Practice Address - City:DE SOTO
Practice Address - State:MO
Practice Address - Zip Code:63020-2586
Practice Address - Country:US
Practice Address - Phone:636-586-6559
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO031260313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO266751809Medicaid