Provider Demographics
NPI:1760475842
Name:LUTHERAN NURSING HOME
Entity Type:Organization
Organization Name:LUTHERAN NURSING HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:TEBBENKAMP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-463-2267
Mailing Address - Street 1:202 S WEST ST
Mailing Address - Street 2:P.O. BOX 849
Mailing Address - City:CONCORDIA
Mailing Address - State:MO
Mailing Address - Zip Code:64020-9643
Mailing Address - Country:US
Mailing Address - Phone:660-463-2267
Mailing Address - Fax:660-463-7116
Practice Address - Street 1:202 S WEST ST
Practice Address - Street 2:
Practice Address - City:CONCORDIA
Practice Address - State:MO
Practice Address - Zip Code:64020-9643
Practice Address - Country:US
Practice Address - Phone:660-463-2267
Practice Address - Fax:660-463-7116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO029282314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO265765Medicare ID - Type Unspecified