Provider Demographics
NPI:1841742855
Name:ALPHA ASSISTED LIVING LLC
Entity Type:Organization
Organization Name:ALPHA ASSISTED LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADM.
Authorized Official - Prefix:MS
Authorized Official - First Name:LEAETTA
Authorized Official - Middle Name:M
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:LPN, ADM
Authorized Official - Phone:573-341-8000
Mailing Address - Street 1:13450 COUNTY ROAD 7040
Mailing Address - Street 2:ALPHA ASSISTED LIVING, LLC
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401
Mailing Address - Country:US
Mailing Address - Phone:573-341-8000
Mailing Address - Fax:573-341-2222
Practice Address - Street 1:13450 CR 7040
Practice Address - Street 2:803 E 12TH ST
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401
Practice Address - Country:US
Practice Address - Phone:573-341-8000
Practice Address - Fax:573-341-2222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-26
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO042404Medicaid