Provider Demographics
NPI:1285674051
Name:MANOR OF ELFINDALE, INC.
Entity Type:Organization
Organization Name:MANOR OF ELFINDALE, INC.
Other - Org Name:THE MANOR OF ELFINDALE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:VETTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-895-3932
Mailing Address - Street 1:1707 W ELFINDALE ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-1246
Mailing Address - Country:US
Mailing Address - Phone:417-831-2273
Mailing Address - Fax:417-831-7409
Practice Address - Street 1:1707 W ELFINDALE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-1246
Practice Address - Country:US
Practice Address - Phone:417-831-2273
Practice Address - Fax:417-831-7409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO031257314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO265804Medicare Oscar/Certification
0922970001Medicare NSC