NPIMap

Organization Active NPI

Licking No 1 LLC

  • Skilled Nursing Facility
  • Licking, MO
National Provider Identifier
1912424607
Registry record updated Aug 24, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Skilled Nursing FacilityTaxonomy code 314000000X
License
046854 Issued in MO
Legal business name
LICKING NO 1 LLC
Practice address
209 Hickory St
Licking, MO 65542
Phone
(573) 674-2111
NPI assigned
Aug 24, 2017
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 24, 2018

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Donald B Bedell
Title
President
Phone
(573) 471-1276

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Skilled Nursing Facility 314000000X 046854 MO Primary

Addresses

Primary practice location

209 Hickory St
Licking, MO 65542

Mailing address

731 N Main St
Sikeston, MO 63801-2151
Phone (573) 471-1276

Other names 1

  • Hickory Manor Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MO

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20171122002453 MO Part A Provider - Skilled Nursing Facility 0345507521 Practice locations: Licking, MO

Skilled nursing facility certification: CCN 265632

Legal name
LICKING NO 1 LLC
Doing business as
HICKORY MANOR
Certification status
Active
Provider type (POS)
Nursing home – SNF/NF dual certification
Participating since
Apr 3, 1996
Last certification
Jan 23, 2025
Beds
60
Ownership / control type
Individual
Most recent change of ownership
Aug 1, 2017
Organization structure
LLCProprietary
Enrollment address
209 Hickory St
Licking, MO 65542-9847
Nursing home name
HICKORY MANOR

Care Compare: Nursing home

Medicare Care Compare
Listed as
Hickory ManorCCN 265632
Overall star rating
2 of 5
Health inspections
3 of 5
Staffing
2 of 5
Quality measures
1 of 5
Type
Medicare and Medicaid
Ownership
For profit - Individual
Certified
Apr 3, 1996
Medicare certification status
ActiveFrom the Provider of Services file
Certified beds
6037.1 residents per day on average

Processed by Care Compare on Aug 1, 2026.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
26D0652411Licking No 1 Dba Hickory Manor209 Hickory, Licking, MO 65542Certificate of waiverAug 31, 2026

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 16

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Jonathan R Beers Individual Operational/Managerial Control Sep 1, 2024
Adp of the SNF Sep 1, 2024
Individual Adp of the SNF Jan 1, 2000
Sovereign Healthcare Group LLC Organization, Sikeston, MO LLC, Medical provider/supplier Operational/Managerial Control Apr 23, 2021
Adp of the SNF Apr 6, 2025
FG LLC Organization, Sikeston, MO LLC Adp of the SNF Aug 1, 2017
Mid States Inc Organization, Sikeston, MO Corporation, Management services company Adp of the SNF Aug 1, 2017
Van de Ven LLC Organization, Cape Girardeau, MO LLC Adp of the SNF Aug 1, 2017
Individual Adp of the SNF Jan 1, 2000
Todd Beaird Individual Operational/Managerial Control Jan 1, 2022
Adp of the SNF Jan 1, 2022
Donald B Bedell Individual Operational/Managerial Control May 24, 2017
Angie Warner Individual Operational/Managerial Control Jun 16, 2023
Adp of the SNF Jun 16, 2023
The Licking Exempt Trust Organization, Sikeston, MO Trustee of the SNF May 24, 2017
Direct Ownership Interest May 24, 2017 100%
Tina Caudill Individual Operational/Managerial Control Jan 15, 2026
Adp of the SNF Jan 15, 2026
Forvis Mazars LLP Organization, Springfield, MO Consulting firm Adp of the SNF Aug 16, 2021
Agh1 LLC Organization, Sikeston, MO LLC, Management services company, Consulting firm Operational/Managerial Control Aug 1, 2017
Adp of the SNF Apr 14, 2025
The City of Licking Organization, Licking, MO Adp of the SNF Aug 1, 2017
Lindi Diana Schmitt Individual Operational/Managerial Control Nov 27, 2023
Adp of the SNF Nov 27, 2023

Owners & managing parties with NPI records 2

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Facilities with the same owner 36

Facilities that share an organizational owner with 5% or greater ownership or operational control.

View all 36

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

Affiliated clinicians 2

Clinicians who list this facility as an affiliation in Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1503532800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1535068800000",
    "number": "1912424607",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "731 N MAIN ST",
            "city": "SIKESTON",
            "state": "MO",
            "postal_code": "638012151",
            "telephone_number": "573-471-1276"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "209 HICKORY ST",
            "city": "LICKING",
            "state": "MO",
            "postal_code": "65542",
            "telephone_number": "573-674-2111"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LICKING NO 1 LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-08-24",
        "last_updated": "2018-08-24",
        "status": "A",
        "authorized_official_last_name": "BEDELL",
        "authorized_official_first_name": "DONALD",
        "authorized_official_middle_name": "B",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "573-471-1276",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": "MO",
            "license": "046854",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Hickory Manor",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Licking, MO

Sources for this page

Verify at the official NPI Registry.