Provider Demographics
NPI:1669512083
Name:ROCKY RIVER RESORT, INC.
Entity Type:Organization
Organization Name:ROCKY RIVER RESORT, INC.
Other - Org Name:PREFERRED HOME CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING ADMINSTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DANA
Authorized Official - Middle Name:M
Authorized Official - Last Name:SIEGLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-996-3788
Mailing Address - Street 1:109 SMITH DR
Mailing Address - Street 2:
Mailing Address - City:DONIPHAN
Mailing Address - State:MO
Mailing Address - Zip Code:63935-1031
Mailing Address - Country:US
Mailing Address - Phone:573-996-3788
Mailing Address - Fax:573-996-7870
Practice Address - Street 1:109 SMITH DR
Practice Address - Street 2:
Practice Address - City:DONIPHAN
Practice Address - State:MO
Practice Address - Zip Code:63935-1031
Practice Address - Country:US
Practice Address - Phone:573-996-3788
Practice Address - Fax:573-996-7870
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2009-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR149332757Medicaid
AR176942765Medicaid
MO283809101Medicaid
MO263809105Medicaid
AR149331752Medicaid