Provider Demographics
NPI:1306258561
Name:DE LA PIEDRA, ENRIQUE
Entity type:Individual
Prefix:
First Name:ENRIQUE
Middle Name:
Last Name:DE LA PIEDRA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:196 HWY 196
Mailing Address - Street 2:
Mailing Address - City:LINN
Mailing Address - State:MO
Mailing Address - Zip Code:65051-3500
Mailing Address - Country:US
Mailing Address - Phone:573-897-0700
Mailing Address - Fax:573-897-0400
Practice Address - Street 1:196 HWY 196
Practice Address - Street 2:
Practice Address - City:LINN
Practice Address - State:MO
Practice Address - Zip Code:65051-3500
Practice Address - Country:US
Practice Address - Phone:573-897-0700
Practice Address - Fax:573-897-0400
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-22
Last Update Date:2014-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO042107314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility