Healthcare Provider Details

I. General information

NPI: 1235127580
Provider Name (Legal Business Name): APPLETON CITY MANOR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 03/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N OHIO ST
APPLETON CITY MO
64724-1609
US

IV. Provider business mailing address

PO BOX 98
APPLETON CITY MO
64724-0098
US

V. Phone/Fax

Practice location:
  • Phone: 660-476-2128
  • Fax: 660-476-5567
Mailing address:
  • Phone: 660-476-2128
  • Fax: 660-476-5567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number032038
License Number State

VIII. Authorized Official

Name: CHARLES L CONWAY
Title or Position: ADMINISTRATOR
Credential:
Phone: 660-476-2128