Basic Information
| Provider Information | |||||||||
| NPI: | 1275626855 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LAVERNA VILLAGE NURSING HOME INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 279 | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | MO | ||||||||
| PostalCode: | 644850279 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8163243185 | ||||||||
| FaxNumber: | 8163244097 | ||||||||
| Practice Location | |||||||||
| Address1: | 904 HALL AVENUE | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | MO | ||||||||
| PostalCode: | 644850279 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8163243185 | ||||||||
| FaxNumber: | 8163244097 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 07/12/2007 | ||||||||
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| AuthorizedOfficialLastName: | MARINE | ||||||||
| AuthorizedOfficialFirstName: | ROSS | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8163243185 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PLATINUM HEALTH CARE | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 034371 | MO | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 265787 | 01 | MO | MEDICARE PROVIDER # | OTHER |