Provider Demographics
NPI:1619939196
Name:LUTHERAN HOME FOR THE AGED
Entity Type:Organization
Organization Name:LUTHERAN HOME FOR THE AGED
Other - Org Name:LUTHERAN HOME - HOME HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:S
Authorized Official - Last Name:PAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:573-335-0158
Mailing Address - Street 1:2825 BLOOMFIELD RD
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-6335
Mailing Address - Country:US
Mailing Address - Phone:573-334-1515
Mailing Address - Fax:573-986-6216
Practice Address - Street 1:2825 BLOOMFIELD RD
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-6335
Practice Address - Country:US
Practice Address - Phone:573-334-1515
Practice Address - Fax:573-986-6216
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LUTHERAN HOME FOR THE AGED
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-04-03
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO539-9251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO267514Medicare Oscar/Certification