Provider Demographics
NPI:1255436747
Name:KIRKSVILLE MANOR INC
Entity type:Organization
Organization Name:KIRKSVILLE MANOR INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
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:660-646-5385
Mailing Address - Street 1:1705 E LAHARPE ST
Mailing Address - Street 2:
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501-3927
Mailing Address - Country:US
Mailing Address - Phone:660-665-3774
Mailing Address - Fax:660-627-1991
Practice Address - Street 1:1705 E LAHARPE ST
Practice Address - Street 2:
Practice Address - City:KIRKSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63501-3927
Practice Address - Country:US
Practice Address - Phone:660-665-3774
Practice Address - Fax:660-627-1991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2012-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO017422314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD102020500Medicaid
MD102020500Medicaid