Provider Demographics
NPI:1790805018
Name:MIDWEST HEALTH CARE, LLC
Entity Type:Organization
Organization Name:MIDWEST HEALTH CARE, LLC
Other - Org Name:THE CEDARGATE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JIFI
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-628-7671
Mailing Address - Street 1:2350 KANELL BLVD
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-4036
Mailing Address - Country:US
Mailing Address - Phone:573-785-0188
Mailing Address - Fax:573-785-7321
Practice Address - Street 1:2350 KANELL BLVD
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-4036
Practice Address - Country:US
Practice Address - Phone:573-785-0188
Practice Address - Fax:573-785-7321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2009-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO031347314000000X
MO037135314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO101482008Medicaid
265205Medicare Oscar/Certification