Provider Demographics
NPI:1265988950
Name:DELTA SOUTH SKILLED NURSING AND REHABILITATION LLC
Entity type:Organization
Organization Name:DELTA SOUTH SKILLED NURSING AND REHABILITATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:BOBBIE
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-683-1355
Mailing Address - Street 1:950 FALCON DR
Mailing Address - Street 2:
Mailing Address - City:MALDEN
Mailing Address - State:MO
Mailing Address - Zip Code:63863-1017
Mailing Address - Country:US
Mailing Address - Phone:573-683-1355
Mailing Address - Fax:573-475-8693
Practice Address - Street 1:640 COLONEL GEORGE E DAY PARKWAY
Practice Address - Street 2:
Practice Address - City:SIKESTON
Practice Address - State:MO
Practice Address - Zip Code:63801-0624
Practice Address - Country:US
Practice Address - Phone:573-471-3400
Practice Address - Fax:573-471-4918
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-01
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO100046542Medicaid