Healthcare Provider Details

I. General information

NPI: 1285674051
Provider Name (Legal Business Name): MANOR OF ELFINDALE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 09/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1707 W ELFINDALE ST
SPRINGFIELD MO
65807-1246
US

IV. Provider business mailing address

1707 W ELFINDALE ST
SPRINGFIELD MO
65807-1246
US

V. Phone/Fax

Practice location:
  • Phone: 417-831-2273
  • Fax: 417-831-7409
Mailing address:
  • Phone: 417-831-2273
  • Fax: 417-831-7409

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number031257
License Number StateMO

VII. Legacy identifiers

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

VIII. Authorized Official

Name: MR. JACK DEAN VETTER
Title or Position: PRESIDENT
Credential:
Phone: 402-895-3932