Provider Demographics
NPI:1053307322
Name:POTOSI MANOR, INC.
Entity Type:Organization
Organization Name:POTOSI MANOR, INC.
Other - Org Name:POTOSI MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SHAREHOLDER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:C
Authorized Official - Last Name:LINCOLN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-746-7100
Mailing Address - Street 1:307 S HIGHWAY 21
Mailing Address - Street 2:
Mailing Address - City:POTOSI
Mailing Address - State:MO
Mailing Address - Zip Code:63664-9317
Mailing Address - Country:US
Mailing Address - Phone:573-438-3225
Mailing Address - Fax:573-438-1230
Practice Address - Street 1:307 S HIGHWAY 21
Practice Address - Street 2:
Practice Address - City:POTOSI
Practice Address - State:MO
Practice Address - Zip Code:63664-9317
Practice Address - Country:US
Practice Address - Phone:573-438-3225
Practice Address - Fax:573-438-1230
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-22
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO031634314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO16667131OtherSTATE ID
MO108841503Medicaid
MO108841503Medicaid