Healthcare Provider Details

I. General information

NPI: 1891736690
Provider Name (Legal Business Name): HEARTLAND-WILLOW LANE OF BUTLER MO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 04/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

416 S HIGH ST
BUTLER MO
64730-1827
US

IV. Provider business mailing address

333 N SUMMIT ST ATTN BARRY LAZARUS
TOLEDO OH
43604-1531
US

V. Phone/Fax

Practice location:
  • Phone: 660-679-6158
  • Fax: 660-679-4243
Mailing address:
  • Phone: 419-252-5541
  • Fax: 419-252-5548

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number032782
License Number StateMO

VIII. Authorized Official

Name: MR. BARRY A LAZARUS
Title or Position: VICE PRESIDENT - REIMBURSEMENTS
Credential:
Phone: 419-252-5541