Healthcare Provider Details

I. General information

NPI: 1811911290
Provider Name (Legal Business Name): MEXICO MANOR, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

219 E BOLIVAR ST
MEXICO MO
65265-2637
US

IV. Provider business mailing address

219 E BOLIVAR ST
MEXICO MO
65265-2637
US

V. Phone/Fax

Practice location:
  • Phone: 573-581-0335
  • Fax: 573-581-7818
Mailing address:
  • Phone: 573-581-0335
  • Fax: 573-581-7818

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number032192
License Number StateMO

VIII. Authorized Official

Name: MS. MELDINA L KENNEMORE
Title or Position: ADMINISTRATOR
Credential:
Phone: 573-581-0335