Provider Demographics
NPI:1588705073
Name:MANOR GROVE, INC.
Entity type:Organization
Organization Name:MANOR GROVE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:D
Authorized Official - Last Name:ERRICO
Authorized Official - Suffix:
Authorized Official - Credentials:MSN, LNHA
Authorized Official - Phone:314-965-0864
Mailing Address - Street 1:711 S KIRKWOOD RD
Mailing Address - Street 2:
Mailing Address - City:KIRKWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63122-5928
Mailing Address - Country:US
Mailing Address - Phone:314-965-0864
Mailing Address - Fax:314-965-0464
Practice Address - Street 1:711 S KIRKWOOD RD
Practice Address - Street 2:
Practice Address - City:KIRKWOOD
Practice Address - State:MO
Practice Address - Zip Code:63122
Practice Address - Country:US
Practice Address - Phone:314-965-0864
Practice Address - Fax:314-965-0464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO031653314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO031653OtherSTATE OPERATING LICENSE
MO102191806Medicaid
MO265833Medicare Oscar/Certification