Provider Demographics
NPI:1285766113
Name:VICKY L WINICK
Entity type:Organization
Organization Name:VICKY L WINICK
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:VICKY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:WINICK
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:573-756-2426
Mailing Address - Street 1:PO BOX 510
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640-0510
Mailing Address - Country:US
Mailing Address - Phone:573-756-2426
Mailing Address - Fax:573-756-6774
Practice Address - Street 1:5858 BUSIEK RD
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-7325
Practice Address - Country:US
Practice Address - Phone:573-756-2426
Practice Address - Fax:573-756-6774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0312323104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO267915304Medicaid