Provider Demographics
NPI:1801038724
Name:PACIFIC CARE CENTER LLC
Entity Type:Organization
Organization Name:PACIFIC CARE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:GRETCHEN
Authorized Official - Middle Name:R
Authorized Official - Last Name:ROBERTS-HOAGLIN
Authorized Official - Suffix:
Authorized Official - Credentials:RN LICENSED NURSIN
Authorized Official - Phone:636-271-4222
Mailing Address - Street 1:105 SOUTH SIXTH STREET
Mailing Address - Street 2:
Mailing Address - City:PACIFIC
Mailing Address - State:MO
Mailing Address - Zip Code:63069
Mailing Address - Country:US
Mailing Address - Phone:636-271-4222
Mailing Address - Fax:636-257-8002
Practice Address - Street 1:105 SOUTH SIXTH STREET
Practice Address - Street 2:
Practice Address - City:PACIFIC
Practice Address - State:MO
Practice Address - Zip Code:63069
Practice Address - Country:US
Practice Address - Phone:636-271-4222
Practice Address - Fax:636-257-8002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-25
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO036467314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO102343001Medicaid
MO265337Medicare Oscar/Certification