Provider Demographics
NPI:1801880547
Name:SALT RIVER NURSING HOME DISTRICT
Entity type:Organization
Organization Name:SALT RIVER NURSING HOME DISTRICT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-588-4175
Mailing Address - Street 1:142 SHELBY PLAZA RD
Mailing Address - Street 2:
Mailing Address - City:SHELBINA
Mailing Address - State:MO
Mailing Address - Zip Code:63468-1065
Mailing Address - Country:US
Mailing Address - Phone:573-588-4175
Mailing Address - Fax:573-588-2020
Practice Address - Street 1:142 SHELBY PLAZA RD
Practice Address - Street 2:
Practice Address - City:SHELBINA
Practice Address - State:MO
Practice Address - Zip Code:63468-1065
Practice Address - Country:US
Practice Address - Phone:573-588-4175
Practice Address - Fax:573-588-2020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-08
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO030709314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO101776904Medicaid
MO265694Medicare Oscar/Certification