Provider Demographics
NPI:1497788525
Name:COOPER COUNTY NURSING HOME DISTRICT NO 1
Entity Type:Organization
Organization Name:COOPER COUNTY NURSING HOME DISTRICT NO 1
Other - Org Name:KATY MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GINA
Authorized Official - Middle Name:
Authorized Official - Last Name:TWENTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-834-3111
Mailing Address - Street 1:PO BOX 8
Mailing Address - Street 2:
Mailing Address - City:PILOT GROVE
Mailing Address - State:MO
Mailing Address - Zip Code:65276-0008
Mailing Address - Country:US
Mailing Address - Phone:660-834-3111
Mailing Address - Fax:
Practice Address - Street 1:205 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:PILOT GROVE
Practice Address - State:MO
Practice Address - Zip Code:65276-1111
Practice Address - Country:US
Practice Address - Phone:660-834-3111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2014-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO031713314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO102642600Medicaid
MO265801Medicare Oscar/Certification