Provider Demographics
NPI:1215901921
Name:VIENNA NURSING & REHAB LLC
Entity type:Organization
Organization Name:VIENNA NURSING & REHAB LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:C
Authorized Official - Last Name:LINCOLN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-481-9625
Mailing Address - Street 1:174 BALLPARK ROAD
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:MO
Mailing Address - Zip Code:65582-8043
Mailing Address - Country:US
Mailing Address - Phone:573-422-3177
Mailing Address - Fax:573-422-3079
Practice Address - Street 1:174 BALLPARK ROAD
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:MO
Practice Address - Zip Code:65582-8043
Practice Address - Country:US
Practice Address - Phone:573-422-3177
Practice Address - Fax:573-422-3079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-17
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO028504314000000X
MO035364314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO102018900Medicaid
MO102018900Medicaid