Provider Demographics
NPI:1487728887
Name:PALLADIAN SENIOR CARE OF POPLAR BLUFF LLC.
Entity type:Organization
Organization Name:PALLADIAN SENIOR CARE OF POPLAR BLUFF LLC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:NEWMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-686-5242
Mailing Address - Street 1:PO BOX 340
Mailing Address - Street 2:2711 DEBBIE LANE
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63902-0340
Mailing Address - Country:US
Mailing Address - Phone:573-686-5242
Mailing Address - Fax:573-686-3637
Practice Address - Street 1:2711 DEBBIE LN
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-2651
Practice Address - Country:US
Practice Address - Phone:573-686-5242
Practice Address - Fax:573-686-3637
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO032301310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO266734904Medicaid
MO266734904Medicaid