Provider Demographics
NPI:1750379095
Name:DADE COUNTY NURSING HOME DISTRICT
Entity type:Organization
Organization Name:DADE COUNTY NURSING HOME DISTRICT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERRIESHA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:HUDDLESTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-637-5315
Mailing Address - Street 1:400 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65661-1405
Mailing Address - Country:US
Mailing Address - Phone:417-637-5315
Mailing Address - Fax:417-637-5281
Practice Address - Street 1:400 BROAD ST
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:MO
Practice Address - Zip Code:65661-1405
Practice Address - Country:US
Practice Address - Phone:417-637-5315
Practice Address - Fax:417-637-5281
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-11
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO031395314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO101485001Medicaid
MO101485001Medicaid
MO=========OtherFEDERAL ID NUMBER