Healthcare Provider Details

I. General information

NPI: 1578565578
Provider Name (Legal Business Name): PINE VIEW MANOR, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 11/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 N PINEVIEW STREET
STANBERRY MO
64489-1509
US

IV. Provider business mailing address

307 N PINEVIEW STREET
STANBERRY MO
64489-1509
US

V. Phone/Fax

Practice location:
  • Phone: 660-783-2118
  • Fax: 660-783-2691
Mailing address:
  • Phone: 660-783-2118
  • Fax: 660-783-2691

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number031426
License Number StateMO

VII. Legacy identifiers

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

# 1
Identifier101493302
Identifier TypeMEDICAID
Identifier StateMO
Identifier Issuer

VIII. Authorized Official

Name: MR. JERRY B DOERHOFF
Title or Position: ADMINISTRATOR
Credential:
Phone: 660-783-2118