Provider Demographics
NPI:1154588085
Name:ELDERCARE OF MID-MISSOURI IX, INC.
Entity type:Organization
Organization Name:ELDERCARE OF MID-MISSOURI IX, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:LIERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-477-3280
Mailing Address - Street 1:2601 FAIR ST
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:MO
Mailing Address - Zip Code:64601-3525
Mailing Address - Country:US
Mailing Address - Phone:636-477-3280
Mailing Address - Fax:
Practice Address - Street 1:2601 FAIR ST
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:MO
Practice Address - Zip Code:64601-3525
Practice Address - Country:US
Practice Address - Phone:660-646-1230
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-19
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO101488005Medicaid
MO265785Medicare Oscar/Certification