Provider Demographics
NPI:1669433629
Name:QUAIL CREEK SKILLED NURSING, LLC
Entity type:Organization
Organization Name:QUAIL CREEK SKILLED NURSING, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:REIKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-889-1275
Mailing Address - Street 1:1514 WEST LARK
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65810
Mailing Address - Country:US
Mailing Address - Phone:417-889-1275
Mailing Address - Fax:417-881-0657
Practice Address - Street 1:1514 WEST LARK
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65810
Practice Address - Country:US
Practice Address - Phone:417-889-1275
Practice Address - Fax:417-881-0657
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-30
Last Update Date:2013-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO032174314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO102679008Medicaid
265799Medicare Oscar/Certification