Provider Demographics
NPI:1558362087
Name:LACOBA HOMES INC
Entity Type:Organization
Organization Name:LACOBA HOMES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:BALDUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-235-7895
Mailing Address - Street 1:PO BOX 885
Mailing Address - Street 2:
Mailing Address - City:MONETT
Mailing Address - State:MO
Mailing Address - Zip Code:65708-0885
Mailing Address - Country:US
Mailing Address - Phone:417-235-7895
Mailing Address - Fax:417-235-0093
Practice Address - Street 1:850 HWY 60 E
Practice Address - Street 2:
Practice Address - City:MONETT
Practice Address - State:MO
Practice Address - Zip Code:65708-9376
Practice Address - Country:US
Practice Address - Phone:417-235-7895
Practice Address - Fax:417-235-0093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO102935707Medicaid
MO265634Medicare Oscar/Certification