Provider Demographics
NPI:1790879500
Name:CHRISTIAN HEALTH CARE OF SPRINGFIELD WEST PARK
Entity Type:Organization
Organization Name:CHRISTIAN HEALTH CARE OF SPRINGFIELD WEST PARK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:STAYTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-891-9939
Mailing Address - Street 1:5302 VILLAGE PKWY
Mailing Address - Street 2:SUITE 1
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-8102
Mailing Address - Country:US
Mailing Address - Phone:479-464-0200
Mailing Address - Fax:479-464-8098
Practice Address - Street 1:3405 W MOUNT VERNON ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65802-5241
Practice Address - Country:US
Practice Address - Phone:417-891-9939
Practice Address - Fax:417-891-9928
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO027442314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
265575Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER