Provider Demographics
NPI:1962507459
Name:JEFFERSON CITY MANOR INC
Entity Type:Organization
Organization Name:JEFFERSON CITY MANOR INC
Other - Org Name:JEFFERSON CITY MANOR CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:C
Authorized Official - Last Name:SCHEULEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-556-6240
Mailing Address - Street 1:1720 VIETH DR
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-2056
Mailing Address - Country:US
Mailing Address - Phone:573-635-6193
Mailing Address - Fax:573-659-8925
Practice Address - Street 1:1720 VIETH DR
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-2056
Practice Address - Country:US
Practice Address - Phone:573-635-6193
Practice Address - Fax:573-659-8925
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2016-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO017299314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO102159605Medicaid
265285Medicare Oscar/Certification