1104235548 NPI number — GARDEN VILLAS OF SOUTH COUNTY, INC.

Table of content: (NPI 1104235548)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104235548 NPI number — GARDEN VILLAS OF SOUTH COUNTY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GARDEN VILLAS OF SOUTH COUNTY, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104235548
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/11/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14805 N OUTER 40 RD
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
CHESTERFIELD
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63017-6060
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
636-733-7000
Provider Business Mailing Address Fax Number:
636-733-7010

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13457 TESSON FERRY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63128-4010
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-843-7788
Provider Business Practice Location Address Fax Number:
314-843-7845
Provider Enumeration Date:
08/11/2014

Additional Information

Authorized Official

Authorized Official Last Name:
HARTMANN
Authorized Official First Name:
GAIL
Authorized Official Middle Name:
LEE
Authorized Official Title or Position:
TREASURER
Authorized Official Telephone Number:
636-733-7000

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  041921 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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