Healthcare Provider Details

I. General information

NPI: 1972649705
Provider Name (Legal Business Name): GASCONADE MANOR NURSING HOME DISTRICT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 09/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1910 NURSING HOME ROAD
OWENSVILLE MO
65066-2844
US

IV. Provider business mailing address

PO BOX 520 1910 NURSING HOME ROAD
OWENSVILLE MO
65066-0520
US

V. Phone/Fax

Practice location:
  • Phone: 573-437-4101
  • Fax: 573-437-3925
Mailing address:
  • Phone: 573-437-4101
  • Fax: 573-437-3925

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number031054
License Number StateMO

VIII. Authorized Official

Name: MRS. CRYSTAL LYNN RAY
Title or Position: ADMINISTRATOR
Credential: ADMINISTRATOR
Phone: 573-437-4101