Provider Demographics
NPI:1275626855
Name:LAVERNA VILLAGE NURSING HOME INC.
Entity Type:Organization
Organization Name:LAVERNA VILLAGE NURSING HOME INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROSS
Authorized Official - Middle Name:P
Authorized Official - Last Name:MARINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-324-3185
Mailing Address - Street 1:PO BOX 279
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:MO
Mailing Address - Zip Code:64485-0279
Mailing Address - Country:US
Mailing Address - Phone:816-324-3185
Mailing Address - Fax:816-324-4097
Practice Address - Street 1:904 HALL AVENUE
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:MO
Practice Address - Zip Code:64485-0279
Practice Address - Country:US
Practice Address - Phone:816-324-3185
Practice Address - Fax:816-324-4097
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PLATINUM HEALTH CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-02
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO034371314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO265787OtherMEDICARE PROVIDER #