Provider Demographics
NPI:1124275482
Name:PREMIER RESIDENTIAL CARE LLC
Entity type:Organization
Organization Name:PREMIER RESIDENTIAL CARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:PAULINE
Authorized Official - Middle Name:S
Authorized Official - Last Name:GUNTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-345-0310
Mailing Address - Street 1:967 NORTH MAPLE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:MO
Mailing Address - Zip Code:65622
Mailing Address - Country:US
Mailing Address - Phone:417-345-0310
Mailing Address - Fax:
Practice Address - Street 1:967 NORTH MAPLE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:MO
Practice Address - Zip Code:65622
Practice Address - Country:US
Practice Address - Phone:417-345-0310
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-19
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO035613310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1891979126Medicaid