Provider Demographics
NPI:1871630590
Name:KNIGHTS OF COLUMBUS 3151 ST. FRANCIS XAVIER
Entity Type:Organization
Organization Name:KNIGHTS OF COLUMBUS 3151 ST. FRANCIS XAVIER
Other - Org Name:COLUMBUS CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:E
Authorized Official - Last Name:PEARSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-471-1902
Mailing Address - Street 1:829 TANNER ST
Mailing Address - Street 2:
Mailing Address - City:SIKESTON
Mailing Address - State:MO
Mailing Address - Zip Code:63801-2261
Mailing Address - Country:US
Mailing Address - Phone:573-471-1902
Mailing Address - Fax:573-471-3494
Practice Address - Street 1:829 TANNER ST
Practice Address - Street 2:
Practice Address - City:SIKESTON
Practice Address - State:MO
Practice Address - Zip Code:63801-2261
Practice Address - Country:US
Practice Address - Phone:573-471-1902
Practice Address - Fax:573-471-3494
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO601261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO294806203Medicaid