Provider Demographics
NPI:1619932662
Name:MANOR OF MALVERN INC.
Entity Type:Organization
Organization Name:MANOR OF MALVERN INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:MORSE BOLTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-624-8661
Mailing Address - Street 1:903 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:IA
Mailing Address - Zip Code:51551-4059
Mailing Address - Country:US
Mailing Address - Phone:712-624-8661
Mailing Address - Fax:712-624-8127
Practice Address - Street 1:903 2ND AVE
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:IA
Practice Address - Zip Code:51551-4059
Practice Address - Country:US
Practice Address - Phone:712-624-8661
Practice Address - Fax:712-624-8127
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-20
Last Update Date:2010-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0807834Medicaid
IA165244Medicare Oscar/Certification
IA0807834Medicaid