Healthcare Provider Details

I. General information

NPI: 1104887561
Provider Name (Legal Business Name): LAWRENCE COUNTY NURSING HOME DISTRICT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2006
Last Update Date: 12/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 CARL ALLEN ST
MOUNT VERNON MO
65712-1612
US

IV. Provider business mailing address

915 CARL ALLEN ST
MOUNT VERNON MO
65712-1612
US

V. Phone/Fax

Practice location:
  • Phone: 417-466-2183
  • Fax: 417-466-3003
Mailing address:
  • Phone: 417-466-2183
  • Fax: 417-466-3003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number031083
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number030910
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number039010
License Number StateMO

VIII. Authorized Official

Name: MRS. LORENA BETH HILL
Title or Position: ADMINISTRATOR
Credential:
Phone: 417-466-2183