Provider Demographics
NPI:1710085626
Name:TABOR MANOR CARE CENTER INC
Entity Type:Organization
Organization Name:TABOR MANOR CARE CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LEONARD
Authorized Official - Middle Name:B
Authorized Official - Last Name:WORCESTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-629-2645
Mailing Address - Street 1:PO BOX 180
Mailing Address - Street 2:209 MAIN ST
Mailing Address - City:TABOR
Mailing Address - State:IA
Mailing Address - Zip Code:51653
Mailing Address - Country:US
Mailing Address - Phone:712-629-2645
Mailing Address - Fax:712-629-6665
Practice Address - Street 1:209 MAIN ST
Practice Address - Street 2:
Practice Address - City:TABOR
Practice Address - State:IA
Practice Address - Zip Code:51653
Practice Address - Country:US
Practice Address - Phone:712-629-2645
Practice Address - Fax:712-629-6665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
313M00000X
IA360577314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Not Answered314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0803957Medicaid
165546Medicare ID - Type Unspecified