Provider Demographics
NPI:1598819112
Name:CATHEDRAL ROCK OF ROLLA INC
Entity Type:Organization
Organization Name:CATHEDRAL ROCK OF ROLLA INC
Other - Org Name:HERITAGE PARK SKILLED CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:KENT
Authorized Official - Last Name:HARRINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-335-4111
Mailing Address - Street 1:306 W 7TH ST STE 415
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76102-4905
Mailing Address - Country:US
Mailing Address - Phone:817-335-4111
Mailing Address - Fax:817-335-0800
Practice Address - Street 1:1200 MCCUTCHEN RD
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-2615
Practice Address - Country:US
Practice Address - Phone:573-364-2311
Practice Address - Fax:573-364-2748
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2008-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO032162314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO101475408Medicaid
MO101475408Medicaid