Healthcare Provider Details

I. General information

NPI: 1295830776
Provider Name (Legal Business Name): PLEASANT VALLEY MANOR INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 07/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6814 SOBBIE ROAD
LIBERTY MO
64068
US

IV. Provider business mailing address

6814 SOBBIE ROAD
LIBERTY MO
64068
US

V. Phone/Fax

Practice location:
  • Phone: 816-781-5277
  • Fax: 816-781-8273
Mailing address:
  • Phone: 816-781-5277
  • Fax: 816-781-8273

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number016612
License Number StateMO

VIII. Authorized Official

Name: MR. HAL JUCKETTE
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 660-646-5385