Provider Demographics
NPI:1689842916
Name:LIFE ENHANCEMENT VILLAGE OF BRANSON
Entity Type:Organization
Organization Name:LIFE ENHANCEMENT VILLAGE OF BRANSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-725-6680
Mailing Address - Street 1:421 OAK RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WALNUT SHADE
Mailing Address - State:MO
Mailing Address - Zip Code:65771-9173
Mailing Address - Country:US
Mailing Address - Phone:417-561-5395
Mailing Address - Fax:417-561-5395
Practice Address - Street 1:421 OAK RIDGE RD
Practice Address - Street 2:
Practice Address - City:WALNUT SHADE
Practice Address - State:MO
Practice Address - Zip Code:65771-9173
Practice Address - Country:US
Practice Address - Phone:417-561-5395
Practice Address - Fax:417-561-5395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-20
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO03285453104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO8611209Medicaid