Provider Demographics
NPI:1336497304
Name:JP MANOR LLC
Entity Type:Organization
Organization Name:JP MANOR LLC
Other - Org Name:POCAHONTAS MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:DEWITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-754-7312
Mailing Address - Street 1:3913 SYLVIAN AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51104-1325
Mailing Address - Country:US
Mailing Address - Phone:712-574-7312
Mailing Address - Fax:712-277-8313
Practice Address - Street 1:700 NW 7TH ST
Practice Address - Street 2:
Practice Address - City:POCAHONTAS
Practice Address - State:IA
Practice Address - Zip Code:50574-2206
Practice Address - Country:US
Practice Address - Phone:712-335-3387
Practice Address - Fax:712-335-4009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-24
Last Update Date:2012-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA760036314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA165461Medicare Oscar/Certification