Provider Demographics
NPI:1932273331
Name:PALLADIAN SENIOR CARE OF POPLAR BLUFF LLC.
Entity Type:Organization
Organization Name:PALLADIAN SENIOR CARE OF POPLAR BLUFF LLC.
Other - Org Name:OAKDALE CARE CENTER RCF
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JASON
Authorized Official - Last Name:MILLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-317-2003
Mailing Address - Street 1:500 NW PLAZA DR STE 712
Mailing Address - Street 2:
Mailing Address - City:SAINT ANN
Mailing Address - State:MO
Mailing Address - Zip Code:63074-2222
Mailing Address - Country:US
Mailing Address - Phone:314-317-2003
Mailing Address - Fax:
Practice Address - Street 1:2704 DEBBIE LN
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-2650
Practice Address - Country:US
Practice Address - Phone:573-686-5242
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0316243104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO266774124Medicaid
MO265556Medicare ID - Type Unspecified