1669512083 NPI number — ROCKY RIVER RESORT, INC.

Table of content: (NPI 1669512083)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669512083 NPI number — ROCKY RIVER RESORT, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROCKY RIVER RESORT, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PREFERRED HOME CARE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1669512083
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/20/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
109 SMITH DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DONIPHAN
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63935-1031
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-996-3788
Provider Business Mailing Address Fax Number:
573-996-7870

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
109 SMITH DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DONIPHAN
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63935-1031
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-996-3788
Provider Business Practice Location Address Fax Number:
573-996-7870
Provider Enumeration Date:
02/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SIEGLER
Authorized Official First Name:
DANA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
BILLING ADMINSTRATOR
Authorized Official Telephone Number:
573-996-3788

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 149332757 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 176942765 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 283809101 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 263809105 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 149331752 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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