Provider Demographics
NPI:1518953819
Name:FORSYTH MANOR, INC.
Entity Type:Organization
Organization Name:FORSYTH MANOR, INC.
Other - Org Name:FORSYTH CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:HUDSPETH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-392-0316
Mailing Address - Street 1:477 COY BLVD
Mailing Address - Street 2:
Mailing Address - City:FORSYTH
Mailing Address - State:MO
Mailing Address - Zip Code:65653-5132
Mailing Address - Country:US
Mailing Address - Phone:417-546-6337
Mailing Address - Fax:417-546-2100
Practice Address - Street 1:477 COY BLVD
Practice Address - Street 2:
Practice Address - City:FORSYTH
Practice Address - State:MO
Practice Address - Zip Code:65653-5132
Practice Address - Country:US
Practice Address - Phone:417-546-6337
Practice Address - Fax:417-546-2100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-22
Last Update Date:2011-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO031673314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO107753402Medicaid
MO15846270OtherSTATE ID
MO107753402Medicaid