Provider Demographics
NPI:1265559280
Name:KENNETT RESIDENTIAL CARE FACILITY II INC
Entity type:Organization
Organization Name:KENNETT RESIDENTIAL CARE FACILITY II INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:GINA
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:STOVERINK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-888-1201
Mailing Address - Street 1:919 S JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:KENNETT
Mailing Address - State:MO
Mailing Address - Zip Code:63857-3803
Mailing Address - Country:US
Mailing Address - Phone:573-888-1201
Mailing Address - Fax:573-888-0114
Practice Address - Street 1:919 S JACKSON ST
Practice Address - Street 2:
Practice Address - City:KENNETT
Practice Address - State:MO
Practice Address - Zip Code:63857-3803
Practice Address - Country:US
Practice Address - Phone:573-888-1201
Practice Address - Fax:573-888-0114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO032637310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO266730803Medicaid