Provider Demographics
NPI:1851844393
Name:DESOTO INVESTMENT GROUP LLC
Entity Type:Organization
Organization Name:DESOTO INVESTMENT GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:BROOKE
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:BIGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-425-3062
Mailing Address - Street 1:375 FONTANA LN
Mailing Address - Street 2:
Mailing Address - City:LINN CREEK
Mailing Address - State:MO
Mailing Address - Zip Code:65052-2584
Mailing Address - Country:US
Mailing Address - Phone:417-425-3062
Mailing Address - Fax:
Practice Address - Street 1:3260 BAISCH DR
Practice Address - Street 2:
Practice Address - City:DE SOTO
Practice Address - State:MO
Practice Address - Zip Code:63020-5046
Practice Address - Country:US
Practice Address - Phone:417-425-3062
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-02
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO104685003Medicaid
MO104685003Medicaid