Organization
MISSION LAKE CONVALESCENT CENTER INC.
Active
Other names
Timberlake Care Center
Organization subpart
No
Provider details
NPI number
Authorized official
MR. LOREN REA (PRESIDENT)
(816) 941-3006
Entity
Organization
Contact information
Practice address
12110 HOLMES RD, KANSAS CITY, MO 64145-1707
(816) 941-3006
(816) 942-8049
Mailing address
12110 HOLMES RD, KANSAS CITY, MO 64145-1707
(816) 941-3006
(816) 942-8049
Taxonomy
Speciality
Code
Description
License number
State
314000000X
Skilled Nursing Facility
Primary
034738
MO
332BN1400X
Nursing Facility Supplies (DME)
032111
MO
332BP3500X
Parenteral & Enteral Nutrition Supplies (DME)
032111
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
032111
PROVIDER
MO
05
—
102084506
—
MO
01
—
1770528986
NPI
MO
Enumeration date
06/19/2006
Last updated
02/19/2013
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