1922320795 NPI number — MERIDIAN VILLAGE ASSOCIATION

Table of content: (NPI 1922320795)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922320795 NPI number — MERIDIAN VILLAGE ASSOCIATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MERIDIAN VILLAGE ASSOCIATION
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:
MERIDIAN VILLAGE CARE CENTER
Provider Other Organization Name Type Code:
3
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:
1922320795
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/25/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1150 HANLEY INDUSTRIAL CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63144-1910
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-968-9313
Provider Business Mailing Address Fax Number:
314-968-5590

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
27 AUERBACH PLACE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLEN CARBON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62034
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-288-3700
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/22/2010

Additional Information

Authorized Official

Authorized Official Last Name:
SNEED
Authorized Official First Name:
CHADWICK
Authorized Official Middle Name:
Authorized Official Title or Position:
SR VICE PRESIDENT OF FINANCE
Authorized Official Telephone Number:
314-968-9313

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  1957652 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 371415587001 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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