Provider Demographics
NPI:1235127580
Name:APPLETON CITY MANOR LLC
Entity Type:Organization
Organization Name:APPLETON CITY MANOR LLC
Other - Org Name:APPLETON CITY MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:L
Authorized Official - Last Name:CONWAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-476-2128
Mailing Address - Street 1:PO BOX 98
Mailing Address - Street 2:
Mailing Address - City:APPLETON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64724-0098
Mailing Address - Country:US
Mailing Address - Phone:660-476-2128
Mailing Address - Fax:660-476-5567
Practice Address - Street 1:600 N OHIO ST
Practice Address - Street 2:
Practice Address - City:APPLETON CITY
Practice Address - State:MO
Practice Address - Zip Code:64724-1609
Practice Address - Country:US
Practice Address - Phone:660-476-2128
Practice Address - Fax:660-476-5567
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-11
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
032038313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO101484202Medicaid
MO265843Medicare UPIN