Provider Demographics
NPI:1043291255
Name:PEARL'S II EDEN FOR ELDERS LLC
Entity type:Organization
Organization Name:PEARL'S II EDEN FOR ELDERS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:CHERYLE
Authorized Official - Last Name:BAGLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-748-4407
Mailing Address - Street 1:611 N COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:MO
Mailing Address - Zip Code:64673-1051
Mailing Address - Country:US
Mailing Address - Phone:660-748-4407
Mailing Address - Fax:660-748-4409
Practice Address - Street 1:611 N COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:MO
Practice Address - Zip Code:64673-1051
Practice Address - Country:US
Practice Address - Phone:660-748-4407
Practice Address - Fax:660-748-4409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-07
Last Update Date:2012-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO031116314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO265796OtherOSCAR
MO101493708Medicaid