Provider Demographics
NPI:1376539320
Name:LUTHERAN HOME FOR THE AGED
Entity Type:Organization
Organization Name:LUTHERAN HOME FOR THE AGED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:PAT
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCANN
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:573-335-0158
Mailing Address - Street 1:2825 BLOOMFIELD RD
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-6335
Mailing Address - Country:US
Mailing Address - Phone:573-335-0158
Mailing Address - Fax:573-986-6312
Practice Address - Street 1:2825 BLOOMFIELD RD
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-6335
Practice Address - Country:US
Practice Address - Phone:573-335-0158
Practice Address - Fax:573-986-6312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-26
Last Update Date:2008-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO030491314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO102445400Medicaid
MO588585505Medicaid
MO288861503Medicaid
MO262445406Medicaid
MO268861507Medicaid
MO292924008Medicaid
MO102445400Medicaid
MO588585505Medicaid