Basic Information
| Provider Information | |||||||||
| NPI: | 1750553830 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VICTORIAN MANOR OF HERMANN INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | VICTORIAN MANOR OF HERMANN | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1015 SPRINGFIELD RD | ||||||||
| Address2: | |||||||||
| City: | OWENSVILLE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 65066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5734372103 | ||||||||
| FaxNumber: | 5734372219 | ||||||||
| Practice Location | |||||||||
| Address1: | 2120 VILLAGE LANE | ||||||||
| Address2: | |||||||||
| City: | HERMANN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 65041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5734865060 | ||||||||
| FaxNumber: | 5734865080 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2008 | ||||||||
| LastUpdateDate: | 03/28/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | QUICK | ||||||||
| AuthorizedOfficialFirstName: | NANCY | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 5734372103 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QH0100X | 032830 | MO | Y | Ambulatory Health Care Facilities | Clinic/Center | Health Service |
No ID Information.