Provider Demographics
NPI:1578565578
Name:PINE VIEW MANOR, INC.
Entity Type:Organization
Organization Name:PINE VIEW MANOR, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:B
Authorized Official - Last Name:DOERHOFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-783-2118
Mailing Address - Street 1:307 N PINEVIEW STREET
Mailing Address - Street 2:
Mailing Address - City:STANBERRY
Mailing Address - State:MO
Mailing Address - Zip Code:64489-1509
Mailing Address - Country:US
Mailing Address - Phone:660-783-2118
Mailing Address - Fax:660-783-2691
Practice Address - Street 1:307 N PINEVIEW STREET
Practice Address - Street 2:
Practice Address - City:STANBERRY
Practice Address - State:MO
Practice Address - Zip Code:64489-1509
Practice Address - Country:US
Practice Address - Phone:660-783-2118
Practice Address - Fax:660-783-2691
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-10
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO031426314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO101493302Medicaid
MO265506Medicare Oscar/Certification
MO26-5506Medicare UPIN