MEDICARE: LACOBA HOMES INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility		MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1558362087
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LACOBA HOMES INC

Provider Business Mailing Address
First Line	:	PO BOX 885
Second Line	:
City	:	MONETT
State	:	MO
Zip	:	65708-0885
Country	:	US
Telephone Number	:	417-235-7895
Fax Number	:	417-235-0093

Provider Business Practice Location Address
First Line	:	850 HWY 60 E
Second Line	:
City	:	MONETT
State	:	MO
Zip	:	65708-9376
Country	:	US
Telephone Number	:	417-235-7895
Fax Number	:	417-235-0093

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. MICHAEL D BALDUS
Credential	:
Telephone Number	:	417-235-7895

Provider Enumeration Date	:	08/09/2005
Last Update Date	:	07/21/2022

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Directions to “LACOBA HOMES INC ” Practice Location

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