Provider Demographics
NPI:1801981089
Name:COMMUNITY MANOR, LLC
Entity type:Organization
Organization Name:COMMUNITY MANOR, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHARO
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIRSHEKAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-701-0600
Mailing Address - Street 1:765 WEBER RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640-3318
Mailing Address - Country:US
Mailing Address - Phone:573-701-0600
Mailing Address - Fax:573-701-0601
Practice Address - Street 1:783 WEBER RD
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-3318
Practice Address - Country:US
Practice Address - Phone:573-756-8998
Practice Address - Fax:573-756-8980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2013-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO031312314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO102481108Medicaid
MO102481108Medicaid