Provider Demographics
NPI:1720236045
Name:REDWOOD MANOR CARE CENTER
Entity Type:Organization
Organization Name:REDWOOD MANOR CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, OPERATER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRISTIE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-468-8150
Mailing Address - Street 1:1194 LANDON RD
Mailing Address - Street 2:
Mailing Address - City:BOURBON
Mailing Address - State:MO
Mailing Address - Zip Code:65441-8218
Mailing Address - Country:US
Mailing Address - Phone:573-468-8150
Mailing Address - Fax:573-860-2601
Practice Address - Street 1:1194 LANDON RD
Practice Address - Street 2:
Practice Address - City:BOURBON
Practice Address - State:MO
Practice Address - Zip Code:65441-8218
Practice Address - Country:US
Practice Address - Phone:573-468-8150
Practice Address - Fax:573-860-2601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-28
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO034144310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOM266774009OtherHEALTH NET IDENTIFIER