Provider Demographics
NPI:1710960455
Name:THE OZARKS METHODIST MANOR
Entity Type:Organization
Organization Name:THE OZARKS METHODIST MANOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA
Authorized Official - Phone:417-258-2573
Mailing Address - Street 1:PO BOX 403
Mailing Address - Street 2:
Mailing Address - City:MARIONVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65705-0403
Mailing Address - Country:US
Mailing Address - Phone:417-258-2573
Mailing Address - Fax:417-258-2240
Practice Address - Street 1:205 SOUTH COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:MARIONVILLE
Practice Address - State:MO
Practice Address - Zip Code:65705-0403
Practice Address - Country:US
Practice Address - Phone:417-258-2573
Practice Address - Fax:417-258-2240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-28
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO031264310400000X
MO039150310400000X
MO030003314000000X
MO039149314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO106881006Medicaid
MO265594Medicare Oscar/Certification