Provider Demographics
NPI:1811929623
Name:OLIVE MOUNTAIN RESIDENTIAL CARE LLC
Entity type:Organization
Organization Name:OLIVE MOUNTAIN RESIDENTIAL CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCIAL MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:NICHOLE
Authorized Official - Last Name:UPTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-532-3045
Mailing Address - Street 1:PO BOX 969
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:MO
Mailing Address - Zip Code:65536-0969
Mailing Address - Country:US
Mailing Address - Phone:417-532-3045
Mailing Address - Fax:417-532-4104
Practice Address - Street 1:25466 N HWY 5
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:MO
Practice Address - Zip Code:65536-0969
Practice Address - Country:US
Practice Address - Phone:417-532-3045
Practice Address - Fax:417-532-4104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO033209310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility