Provider Demographics
NPI:1639195936
Name:HOLMESDALE HEALTHCARE AND REHABILITATION CENTER, LLC
Entity Type:Organization
Organization Name:HOLMESDALE HEALTHCARE AND REHABILITATION CENTER, LLC
Other - Org Name:HOLMESDALE HEALTHCARE AND REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-468-4752
Mailing Address - Street 1:8033 HOLMES RD
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64131-2115
Mailing Address - Country:US
Mailing Address - Phone:816-363-6222
Mailing Address - Fax:816-361-2025
Practice Address - Street 1:8033 HOLMES RD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64131-2115
Practice Address - Country:US
Practice Address - Phone:816-363-6222
Practice Address - Fax:816-361-2025
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUMMIT CARE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-14
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO043417314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO102569001Medicaid
MO102569001Medicaid