Provider Demographics
NPI:1255675617
Name:MANICURE NURSE LLC
Entity Type:Organization
Organization Name:MANICURE NURSE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:GRISWOLD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-663-4239
Mailing Address - Street 1:6329 BLUE RIDGE BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:RAYTOWN
Mailing Address - State:MO
Mailing Address - Zip Code:64133-4880
Mailing Address - Country:US
Mailing Address - Phone:816-569-0453
Mailing Address - Fax:816-569-0480
Practice Address - Street 1:6329 BLUE RIDGE BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:RAYTOWN
Practice Address - State:MO
Practice Address - Zip Code:64133-4880
Practice Address - Country:US
Practice Address - Phone:816-569-0453
Practice Address - Fax:816-569-0480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-23
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X, 251E00000X, 253Z00000X
MOG203100009347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No251B00000XAgenciesCase Management
No253Z00000XAgenciesIn Home Supportive Care
No347C00000XTransportation ServicesPrivate Vehicle
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO4962Medicaid