Healthcare Provider Details

I. General information

NPI: 1316042898
Provider Name (Legal Business Name): ROLLA MANOR, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 11/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 WHITE COLUMNS DRIVE
ROLLA MO
65401
US

IV. Provider business mailing address

1800 WHITE COLUMNS DRIVE
ROLLA MO
65401
US

V. Phone/Fax

Practice location:
  • Phone: 573-364-7766
  • Fax: 573-364-4036
Mailing address:
  • Phone: 573-364-7766
  • Fax: 573-364-1593

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number017746
License Number StateMO

VII. Legacy identifiers

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

# 1
Identifier102122009
Identifier TypeMEDICAID
Identifier StateMO
Identifier Issuer

VIII. Authorized Official

Name: BENJAMIN C. SCHEULEN
Title or Position: CEO
Credential:
Phone: 573-556-6240