Provider Demographics
NPI:1568821965
Name:PETTIS COUNTY ASSISTED LIVING, L.L.C.
Entity Type:Organization
Organization Name:PETTIS COUNTY ASSISTED LIVING, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:DESTEFANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-543-3800
Mailing Address - Street 1:1869 CRAIG PARK CT
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-4122
Mailing Address - Country:US
Mailing Address - Phone:314-543-3800
Mailing Address - Fax:314-543-3880
Practice Address - Street 1:3017 BROOKING PARK AVE
Practice Address - Street 2:
Practice Address - City:SEDALIA
Practice Address - State:MO
Practice Address - Zip Code:65301-9327
Practice Address - Country:US
Practice Address - Phone:660-827-3222
Practice Address - Fax:660-829-2217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-15
Last Update Date:2016-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness