Provider Demographics
NPI:1598735771
Name:POCAHONTAS MANOR CORPORATION
Entity Type:Organization
Organization Name:POCAHONTAS MANOR CORPORATION
Other - Org Name:POCAHONTAS MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:M
Authorized Official - Last Name:BURNS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-215-8611
Mailing Address - Street 1:700 NW 7TH ST
Mailing Address - Street 2:
Mailing Address - City:POCAHONTAS
Mailing Address - State:IA
Mailing Address - Zip Code:50574-2206
Mailing Address - Country:US
Mailing Address - Phone:712-335-3386
Mailing Address - Fax:712-335-4009
Practice Address - Street 1:700 NW 7TH ST
Practice Address - Street 2:
Practice Address - City:POCAHONTAS
Practice Address - State:IA
Practice Address - Zip Code:50574-2206
Practice Address - Country:US
Practice Address - Phone:712-335-3386
Practice Address - Fax:712-335-4009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-23
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA760036314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0806570Medicaid
IA0806570Medicaid