Healthcare Provider Details

I. General information

NPI: 1265091755
Provider Name (Legal Business Name): PACIFIC MANOR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2019
Last Update Date: 09/15/2025
Certification Date: 09/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 S 6TH ST
PACIFIC MO
63069-1328
US

IV. Provider business mailing address

1220 N MAIN ST
SIKESTON MO
63801-4827
US

V. Phone/Fax

Practice location:
  • Phone: 636-271-4222
  • Fax: 636-257-8131
Mailing address:
  • Phone: 573-481-9625
  • Fax: 573-472-0098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: CARLA HEDRICK
Title or Position: CFO
Credential: CFO
Phone: 573-481-9625