1467072280 NPI number — EDGEWOOD MANOR HEALTH CARE CENTER, L.L.C.

Table of content: (NPI 1467072280)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467072280 NPI number — EDGEWOOD MANOR HEALTH CARE CENTER, L.L.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EDGEWOOD MANOR HEALTH CARE CENTER, L.L.C.
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:
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:
1467072280
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1869 CRAIG PARK 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:
63146-4122
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-543-3816
Provider Business Mailing Address Fax Number:
314-226-1736

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11900 JESSICA LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RAYTOWN
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64138-2649
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-358-7858
Provider Business Practice Location Address Fax Number:
816-356-7775
Provider Enumeration Date:
04/22/2020

Additional Information

Authorized Official

Authorized Official Last Name:
DESTEFANE
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
314-543-3816

Provider Taxonomy Codes

  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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