Provider Demographics
NPI:1457127409
Name:THE LODGE AT MANITO, LLC
Entity Type:Organization
Organization Name:THE LODGE AT MANITO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:C
Authorized Official - Last Name:TUTERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:181-644-4090
Mailing Address - Street 1:7611 STATE LINE RD STE 301
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64114-1698
Mailing Address - Country:US
Mailing Address - Phone:816-444-0900
Mailing Address - Fax:
Practice Address - Street 1:1303 S EAST AVE
Practice Address - Street 2:
Practice Address - City:MANITO
Practice Address - State:IL
Practice Address - Zip Code:61546-8910
Practice Address - Country:US
Practice Address - Phone:309-968-5330
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-30
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility