Provider Demographics
NPI:1740385228
Name:LIVINGSTON MANOR INC
Entity Type:Organization
Organization Name:LIVINGSTON MANOR INC
Other - Org Name:LIVINGSTON MANOR CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:HAL
Authorized Official - Middle Name:
Authorized Official - Last Name:JUCKETTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-646-5177
Mailing Address - Street 1:939 E BIRCH DR
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:MO
Mailing Address - Zip Code:64601-2189
Mailing Address - Country:US
Mailing Address - Phone:660-646-5177
Mailing Address - Fax:660-646-5186
Practice Address - Street 1:939 E BIRCH DR
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:MO
Practice Address - Zip Code:64601-2189
Practice Address - Country:US
Practice Address - Phone:660-646-5177
Practice Address - Fax:660-646-5186
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2012-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO017795314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO102201902Medicaid
265621Medicare Oscar/Certification