Provider Demographics
NPI:1538338652
Name:LIFE ENHANCEMENT VILLAGE
Entity type:Organization
Organization Name:LIFE ENHANCEMENT VILLAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KENNY
Authorized Official - Middle Name:L
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-725-6680
Mailing Address - Street 1:732 S GREGG RD
Mailing Address - Street 2:
Mailing Address - City:NIXA
Mailing Address - State:MO
Mailing Address - Zip Code:65714-7419
Mailing Address - Country:US
Mailing Address - Phone:417-725-6671
Mailing Address - Fax:417-725-6671
Practice Address - Street 1:732 S GREGG RD
Practice Address - Street 2:
Practice Address - City:NIXA
Practice Address - State:MO
Practice Address - Zip Code:65714-7419
Practice Address - Country:US
Practice Address - Phone:417-725-6671
Practice Address - Fax:417-725-6671
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-22
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0325423104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO3751109Medicaid