=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891736690
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEARTLAND-WILLOW LANE OF BUTLER MO LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/10/2006
-----------------------------------------------------
Last Update Date | 04/02/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 416 S HIGH ST
-----------------------------------------------------
City | BUTLER
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64730-1827
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 660-679-6158
-----------------------------------------------------
Fax | 660-679-4243
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 333 N SUMMIT ST ATTN BARRY LAZARUS
-----------------------------------------------------
City | TOLEDO
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43604-1531
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-252-5541
-----------------------------------------------------
Fax | 419-252-5548
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT - REIMBURSEMENTS
-----------------------------------------------------
Name | MR. BARRY A LAZARUS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 419-252-5541
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 032782
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------