Provider Demographics
NPI:1205168523
Name:NIRMAL K SAMANTA
Entity type:Organization
Organization Name:NIRMAL K SAMANTA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH -LANGUAGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:NIRMAL
Authorized Official - Middle Name:KUMAR
Authorized Official - Last Name:SAMANTA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD,CCC-SLP
Authorized Official - Phone:573-450-3393
Mailing Address - Street 1:250 BRANDY LN
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-8443
Mailing Address - Country:US
Mailing Address - Phone:573-450-3393
Mailing Address - Fax:573-339-0911
Practice Address - Street 1:250 BRANDY LN
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-8443
Practice Address - Country:US
Practice Address - Phone:573-450-3393
Practice Address - Fax:573-339-0911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-11
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004016682313M00000X, 311500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility