Provider Demographics
NPI:1023001799
Name:MONROE CITY MANOR CARE CENTER, INC
Entity Type:Organization
Organization Name:MONROE CITY MANOR CARE CENTER, INC
Other - Org Name:MONROE CITY MANOR CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALEXANDRA
Authorized Official - Middle Name:L
Authorized Official - Last Name:EDRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-735-4850
Mailing Address - Street 1:1010 HWY 24 & 36 E
Mailing Address - Street 2:
Mailing Address - City:MONROE CITY
Mailing Address - State:MO
Mailing Address - Zip Code:63456
Mailing Address - Country:US
Mailing Address - Phone:573-735-4850
Mailing Address - Fax:573-735-3511
Practice Address - Street 1:1010 HIGHWAY 24 AND 36 E
Practice Address - Street 2:
Practice Address - City:MONROE CITY
Practice Address - State:MO
Practice Address - Zip Code:63456-1116
Practice Address - Country:US
Practice Address - Phone:573-735-4850
Practice Address - Fax:573-735-3511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-26
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO031459314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO102486909Medicaid
MO265574Medicare Oscar/Certification