Provider Demographics
NPI:1558355925
Name:DEACONESS LONG TERM CARE OF MISSOURI, INC.
Entity Type:Organization
Organization Name:DEACONESS LONG TERM CARE OF MISSOURI, INC.
Other - Org Name:ABC HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-487-3600
Mailing Address - Street 1:440 LAFAYETTE AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45220-1022
Mailing Address - Country:US
Mailing Address - Phone:513-487-3600
Mailing Address - Fax:513-487-3653
Practice Address - Street 1:307 E SOUTH ST
Practice Address - Street 2:
Practice Address - City:HARRISONVILLE
Practice Address - State:MO
Practice Address - Zip Code:64701-3241
Practice Address - Country:US
Practice Address - Phone:816-380-7399
Practice Address - Fax:816-380-6352
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-31
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO029252314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO90447-013OtherBLUE CROSS BLUE SHIELD
MO4652284OtherAETNA
MO101472900Medicaid
MO90447-013OtherBLUE CROSS
MO265513Medicare ID - Type UnspecifiedMEDICARE #