Provider Demographics
NPI:1952724932
Name:INDIVIDUAL
Entity Type:Organization
Organization Name:INDIVIDUAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EASTERN REGIONAL DISTRICT MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:GHIRARDI
Authorized Official - Suffix:
Authorized Official - Credentials:RN, BSN
Authorized Official - Phone:314-220-0928
Mailing Address - Street 1:7933 ELMONT RD
Mailing Address - Street 2:
Mailing Address - City:SULLIVAN
Mailing Address - State:MO
Mailing Address - Zip Code:63080-3601
Mailing Address - Country:US
Mailing Address - Phone:314-220-0928
Mailing Address - Fax:573-885-0428
Practice Address - Street 1:1019 WESTSIDE DR
Practice Address - Street 2:
Practice Address - City:CUBA
Practice Address - State:MO
Practice Address - Zip Code:65453-1025
Practice Address - Country:US
Practice Address - Phone:573-885-1607
Practice Address - Fax:573-885-0428
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-28
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010024399251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care