Provider Demographics
NPI:1801991104
Name:WARRENSBURG MANOR INC
Entity type:Organization
Organization Name:WARRENSBURG MANOR INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
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 1:400 CARE CENTER DR
Mailing Address - Street 2:
Mailing Address - City:WARRENSBURG
Mailing Address - State:MO
Mailing Address - Zip Code:64093-3100
Mailing Address - Country:US
Mailing Address - Phone:660-747-2216
Mailing Address - Fax:660-747-0807
Practice Address - Street 1:400 CARE CENTER DR
Practice Address - Street 2:
Practice Address - City:WARRENSBURG
Practice Address - State:MO
Practice Address - Zip Code:64093-3100
Practice Address - Country:US
Practice Address - Phone:660-747-2216
Practice Address - Fax:660-747-0807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO016604314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO108078700Medicaid
MO108078700Medicaid