Healthcare Provider Details

I. General information

NPI: 1124054366
Provider Name (Legal Business Name): CITY OF ADRIAN - ADRIAN MANOR HEALTH AND REHAB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 01/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 W 1ST ST
ADRIAN MO
64720-9998
US

IV. Provider business mailing address

402 W 1ST ST
ADRIAN MO
64720-9998
US

V. Phone/Fax

Practice location:
  • Phone: 816-297-2107
  • Fax: 816-297-4321
Mailing address:
  • Phone: 816-297-2107
  • Fax: 816-297-4321

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number030454
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier101478907
Identifier TypeMEDICAID
Identifier StateMO
Identifier Issuer

VIII. Authorized Official

Name: MR. DOUGLAS G FREDRICKSON
Title or Position: ADMINISTRATOR
Credential:
Phone: 816-297-2107