Deaconess Long Term Care of Missouri, Inc

Primary specialty

Skilled Nursing FacilityTaxonomy code 314000000X

License

029538 Issued in MO

Legal business name

DEACONESS LONG TERM CARE OF MISSOURI, INC

Doing business as

Edgewood Manor

Practice address

11900 Jessica LN
Raytown, MO 64138-2649

Phone

(816) 358-7858

Fax

(816) 353-1514

NPI assigned

Aug 31, 2005

Last updated

Oct 7, 2008By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Carla Brooks

Title

Cfo

Phone

(513) 487-3600

Specialties & licenses 1

Addresses

Other identifiers 5

Other names 1

• Edgewood Manor Doing business as

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1125446400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1223337600000",
    "number": "1164416509",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "440 LAFAYETTE AVE",
            "address_2": "SUITE 400",
            "city": "CINCINNATI",
            "state": "OH",
            "postal_code": "452201022",
            "telephone_number": "513-487-3600",
            "fax_number": "513-487-3653"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "11900 JESSICA LN",
            "city": "RAYTOWN",
            "state": "MO",
            "postal_code": "641382649",
            "telephone_number": "816-358-7858",
            "fax_number": "816-353-1514"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DEACONESS LONG TERM CARE OF MISSOURI, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-08-31",
        "last_updated": "2008-10-07",
        "status": "A",
        "authorized_official_last_name": "BROOKS",
        "authorized_official_first_name": "CARLA",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "513-487-3600"
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": "MO",
            "license": "029538",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "102783800",
            "state": "MO"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PCARE PROVIDER #",
            "identifier": "262783806",
            "state": "MO"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS",
            "identifier": "90399-010",
            "state": "MO"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE SHIELD",
            "identifier": "90399-010",
            "state": "MO"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "AETNA",
            "identifier": "5397477",
            "state": "MO"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Edgewood Manor",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Elizabeth Criswell
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• Robert M Davis, DDS
• Deaconess Long Term Care of Missouri, Inc. (Cedar Valley Health Care)
• Kathryn Danielle Degenhardt, LCSW
• Carrie Lynn Delphia, OT
• Maizey Noel Denton, DC
• Darshan A Deole, DPT

• Skilled Nursing Facility in Raytown, MO
• Providers in Raytown, MO by specialty
• Skilled Nursing Facility in Missouri

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 7, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.