Healthcare Provider Details

I. General information

NPI: 1558362087
Provider Name (Legal Business Name): LACOBA HOMES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 HWY 60 E
MONETT MO
65708-9376
US

IV. Provider business mailing address

PO BOX 885
MONETT MO
65708-0885
US

V. Phone/Fax

Practice location:
  • Phone: 417-235-7895
  • Fax: 417-235-0093
Mailing address:
  • Phone: 417-235-7895
  • Fax: 417-235-0093

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. MICHAEL D BALDUS
Title or Position: ADMINISTRATOR
Credential:
Phone: 417-235-7895