Provider Demographics
NPI:1215438585
Name:THE VILLAS OF JACKSON LLC
Entity type:Organization
Organization Name:THE VILLAS OF JACKSON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:KNOTT
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA
Authorized Official - Phone:573-986-8210
Mailing Address - Street 1:670 BROADRIDGE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MO
Mailing Address - Zip Code:63755
Mailing Address - Country:US
Mailing Address - Phone:573-986-8210
Mailing Address - Fax:573-755-5155
Practice Address - Street 1:670 BROADRIDGE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MO
Practice Address - Zip Code:63755
Practice Address - Country:US
Practice Address - Phone:573-986-8210
Practice Address - Fax:573-755-5155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-22
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO045129310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility