Provider Demographics
NPI:1063424000
Name:COUNTRY MEADOWS NURSING CENTER, LLC
Entity type:Organization
Organization Name:COUNTRY MEADOWS NURSING CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/MANAGING MEMEBER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHARO
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIRSHEKAN
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:573-701-0600
Mailing Address - Street 1:765 WEBER RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640-3318
Mailing Address - Country:US
Mailing Address - Phone:573-701-0600
Mailing Address - Fax:573-701-0601
Practice Address - Street 1:1301 N SAINT JOE DR
Practice Address - Street 2:
Practice Address - City:PARK HILLS
Practice Address - State:MO
Practice Address - Zip Code:63601-1965
Practice Address - Country:US
Practice Address - Phone:573-701-0600
Practice Address - Fax:573-701-0601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO032557314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO265734Medicare ID - Type Unspecified