1750376612 NPI number — DELMAR GARDENS NORTH OPERATING, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750376612 NPI number — DELMAR GARDENS NORTH OPERATING, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DELMAR GARDENS NORTH OPERATING, LLC
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:
1750376612
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/23/2015
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:
4401 PARKER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLACK JACK
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63033-4266
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-355-1516
Provider Business Practice Location Address Fax Number:
314-355-9074
Provider Enumeration Date:
09/16/2005

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: 314000000X , with the licence number:  031168 , 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)

  • Identifier: 102507407 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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