- Enrollment id
- O20090202000050
- Enrollment state
- MO
- Provider type code
- 00-18
- Provider type text
- PART A PROVIDER - SKILLED NURSING FACILITY
- Npi
- 1255436556
- Multiple npi flag
- N
- Ccn
- 265682
- Associate id
- 9537223813
- Organization name
- INDEPENDENCE MANOR INC
- Doing business as name
- INDEPENDENCE MANOR CARE CENTER
- Organization type structure
- CORPORATION
- Proprietary nonprofit
- P
- Nursing home provider name
- INDEPENDENCE MANOR CARE CENTER
- Affiliation entity name
- JUCKETTE FAMILY HOMES
- Affiliation entity id
- 295
- Address line 1
- 1600 S KINGS HWY
- City
- INDEPENDENCE
- State
- MO
- Zip code
- 640551853