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General NPI Number Information
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NPI Number | 1245893296
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Entity Type | Organization
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Legal Business Name | MICHELE VINSON INVESTMENTS LLC DBA BOLIVAR MANOR HOUSE
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Dates
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Enumeration Date | 04/16/2019
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Last Update Date | 04/16/2019
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Provider Practice Location Address
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Address Line | 404 E BROADWAY ST
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City | BOLIVAR
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State | MO
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Zip | 65613-2019
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Country | US
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Telephone | 417-327-5790
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Fax | 417-326-3839
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Provider Business Mailing Address
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Address Line | PO BOX 175
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City | BOLIVAR
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State | MO
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Zip | 65613-0175
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Country | US
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Telephone | 417-327-5790
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Fax | 417-326-3839
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MS. MICHELE RUTHANNE VINSON
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Credential | MEMBER
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Telephone | 417-327-5790
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3104A0625X
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Taxonomy Name | Assisted Living Facility (Mental Illness)
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License Number |
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License Number State |
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