Provider Demographics
NPI:1407913932
Name:MARION CO. NURSING HOME DISTRICT
Entity Type:Organization
Organization Name:MARION CO. NURSING HOME DISTRICT
Other - Org Name:MAPLE LAWN NURSING HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:W
Authorized Official - Last Name:FUNKENBUSCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-769-2213
Mailing Address - Street 1:P.O. BOX 232
Mailing Address - Street 2:
Mailing Address - City:PALMYRA
Mailing Address - State:MO
Mailing Address - Zip Code:63461-0232
Mailing Address - Country:US
Mailing Address - Phone:573-769-2213
Mailing Address - Fax:573-769-2284
Practice Address - Street 1:1410 W LINE ST
Practice Address - Street 2:
Practice Address - City:PALMYRA
Practice Address - State:MO
Practice Address - Zip Code:63461-0232
Practice Address - Country:US
Practice Address - Phone:573-769-2213
Practice Address - Fax:573-769-2284
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2011-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO031493314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO101937209Medicaid
MO265237Medicare ID - Type Unspecified
MO265237Medicare Oscar/Certification