Healthcare Provider Details

I. General information

NPI: 1336497304
Provider Name (Legal Business Name): JP MANOR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2012
Last Update Date: 08/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 NW 7TH ST
POCAHONTAS IA
50574-2206
US

IV. Provider business mailing address

3913 SYLVIAN AVE
SIOUX CITY IA
51104-1325
US

V. Phone/Fax

Practice location:
  • Phone: 712-335-3387
  • Fax: 712-335-4009
Mailing address:
  • Phone: 712-574-7312
  • Fax: 712-277-8313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number760036
License Number StateIA

VIII. Authorized Official

Name: MR. JOSEPH PATRICK DEWITT
Title or Position: VICE PRESIDENT
Credential:
Phone: 712-754-7312