=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295830776
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PLEASANT VALLEY MANOR INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/13/2006
-----------------------------------------------------
Last Update Date | 07/25/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6814 SOBBIE ROAD
-----------------------------------------------------
City | LIBERTY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64068
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-781-5277
-----------------------------------------------------
Fax | 816-781-8273
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6814 SOBBIE ROAD
-----------------------------------------------------
City | LIBERTY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64068
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-781-5277
-----------------------------------------------------
Fax | 816-781-8273
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF OPERATIONS
-----------------------------------------------------
Name | MR. HAL JUCKETTE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 660-646-5385
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 016612
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------