Basic Information
| Provider Information | |||||||||
| NPI: | 1881091239 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | N & R OF LEBANON NORTH LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LEBANON NORTH NURSING & REHAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 596 MORTON RD | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 655363648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4175329173 | ||||||||
| FaxNumber: | 4175328223 | ||||||||
| Practice Location | |||||||||
| Address1: | 596 MORTON RD | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 655363648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4175329173 | ||||||||
| FaxNumber: | 4175328223 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2014 | ||||||||
| LastUpdateDate: | 12/01/2014 | ||||||||
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| AuthorizedOfficialLastName: | DASAL | ||||||||
| AuthorizedOfficialFirstName: | MATHIAS | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5734819625 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 042568 | MO | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 101489409 | 05 | MO | MEDICAID |