Provider Demographics
NPI:1558355735
Name:LEWIS COUNTY NURSING HOME DISTRICT
Entity Type:Organization
Organization Name:LEWIS COUNTY NURSING HOME DISTRICT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SALLY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:PEARL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-288-4454
Mailing Address - Street 1:PO BOX 266
Mailing Address - Street 2:17528 HWY 81 N
Mailing Address - City:CANTON
Mailing Address - State:MO
Mailing Address - Zip Code:63435-0266
Mailing Address - Country:US
Mailing Address - Phone:573-288-4454
Mailing Address - Fax:573-288-5735
Practice Address - Street 1:17528 STATE HIGHWAY 81
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MO
Practice Address - Zip Code:63435-3463
Practice Address - Country:US
Practice Address - Phone:573-288-4454
Practice Address - Fax:573-288-5735
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-02
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO031316314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO101489508Medicaid
MO265360Medicare Oscar/Certification