Healthcare Provider Details

I. General information

NPI: 1497788525
Provider Name (Legal Business Name): COOPER COUNTY NURSING HOME DISTRICT NO 1
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 05/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 PROSPECT AVE
PILOT GROVE MO
65276-1111
US

IV. Provider business mailing address

PO BOX 8
PILOT GROVE MO
65276-0008
US

V. Phone/Fax

Practice location:
  • Phone: 660-834-3111
  • Fax:
Mailing address:
  • Phone: 660-834-3111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number031713
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier102642600
Identifier TypeMEDICAID
Identifier StateMO
Identifier Issuer

VIII. Authorized Official

Name: GINA TWENTER
Title or Position: ADMINISTRATOR
Credential:
Phone: 660-834-3111