Provider Demographics
NPI:1609822113
Name:NORTHPORT HEALTH SERVICES OF MISSOURI, LLC
Entity type:Organization
Organization Name:NORTHPORT HEALTH SERVICES OF MISSOURI, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:CODY
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-391-3600
Mailing Address - Street 1:1300 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:PLEASANT HILL
Mailing Address - State:MO
Mailing Address - Zip Code:64080-1842
Mailing Address - Country:US
Mailing Address - Phone:816-540-2116
Mailing Address - Fax:
Practice Address - Street 1:1300 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PLEASANT HILL
Practice Address - State:MO
Practice Address - Zip Code:64080-1842
Practice Address - Country:US
Practice Address - Phone:816-540-2116
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO102668209Medicaid
MO102668209Medicaid