Provider Demographics
NPI:1013902139
Name:MACON COUNTY NURSING HOME DISTRICT
Entity Type:Organization
Organization Name:MACON COUNTY NURSING HOME DISTRICT
Other - Org Name:LOCH HAVEN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BYRON
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:FREEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-385-3113
Mailing Address - Street 1:701 SUNSET HILLS DR
Mailing Address - Street 2:P O BOX 187
Mailing Address - City:MACON
Mailing Address - State:MO
Mailing Address - Zip Code:63552-2165
Mailing Address - Country:US
Mailing Address - Phone:660-385-3113
Mailing Address - Fax:660-385-2838
Practice Address - Street 1:701 SUNSET HILLS DR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:MO
Practice Address - Zip Code:63552-2165
Practice Address - Country:US
Practice Address - Phone:660-385-3113
Practice Address - Fax:660-385-2838
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-14
Last Update Date:2010-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO030013314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO101490001Medicaid
MO101490001Medicaid