Provider Demographics
NPI:1154327187
Name:MENNONITE HOME ASSOCIATION INC.
Entity Type:Organization
Organization Name:MENNONITE HOME ASSOCIATION INC.
Other - Org Name:BETH HAVEN NURSING HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:KERRI
Authorized Official - Middle Name:
Authorized Official - Last Name:LAUTERBACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-221-6000
Mailing Address - Street 1:2500 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:HANNIBAL
Mailing Address - State:MO
Mailing Address - Zip Code:63401-2600
Mailing Address - Country:US
Mailing Address - Phone:573-221-6000
Mailing Address - Fax:573-221-6172
Practice Address - Street 1:2500 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:HANNIBAL
Practice Address - State:MO
Practice Address - Zip Code:63401-2600
Practice Address - Country:US
Practice Address - Phone:573-221-6000
Practice Address - Fax:573-221-6172
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-23
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO030867314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO101480101Medicaid
MO265108Medicare Oscar/Certification