Basic Information
| Provider Information | |||||||||
| NPI: | 1134212822 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY MANOR, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 765 WEBER RD | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737010600 | ||||||||
| FaxNumber: | 5737010601 | ||||||||
| Practice Location | |||||||||
| Address1: | 783 WEBER RD | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737568998 | ||||||||
| FaxNumber: | 5737568980 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SHIRSHEKAN | ||||||||
| AuthorizedOfficialFirstName: | SHARO | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO/MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 5737010600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | 031313 | MO | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.