Provider Demographics
NPI:1972649705
Name:GASCONADE MANOR NURSING HOME DISTRICT
Entity Type:Organization
Organization Name:GASCONADE MANOR NURSING HOME DISTRICT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:RAY
Authorized Official - Suffix:
Authorized Official - Credentials:ADMINISTRATOR
Authorized Official - Phone:573-437-4101
Mailing Address - Street 1:PO BOX 520
Mailing Address - Street 2:1910 NURSING HOME ROAD
Mailing Address - City:OWENSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65066-0520
Mailing Address - Country:US
Mailing Address - Phone:573-437-4101
Mailing Address - Fax:573-437-3925
Practice Address - Street 1:1910 NURSING HOME ROAD
Practice Address - Street 2:
Practice Address - City:OWENSVILLE
Practice Address - State:MO
Practice Address - Zip Code:65066-2844
Practice Address - Country:US
Practice Address - Phone:573-437-4101
Practice Address - Fax:573-437-3925
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2014-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO031054314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO101486702Medicaid
MO265546Medicare Oscar/Certification