Provider Demographics
NPI:1699765644
Name:MARANATHA VILLAGE, INC.
Entity type:Organization
Organization Name:MARANATHA VILLAGE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNI
Authorized Official - Middle Name:S
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-833-0016
Mailing Address - Street 1:233 E NORTON RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65803-3633
Mailing Address - Country:US
Mailing Address - Phone:417-833-0016
Mailing Address - Fax:417-833-6659
Practice Address - Street 1:233 E NORTON RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65803-3633
Practice Address - Country:US
Practice Address - Phone:417-833-0016
Practice Address - Fax:417-833-6659
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-21
Last Update Date:2009-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO031691314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO101490704Medicaid
MO265475Medicare Oscar/Certification
MO101490704Medicaid