Basic Information
| Provider Information | |||||||||
| NPI: | 1144301144 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST JOE MANOR INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10 LAKE DR | ||||||||
| Address2: | |||||||||
| City: | BONNE TERRE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 636281820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733582800 | ||||||||
| FaxNumber: | 5733581090 | ||||||||
| Practice Location | |||||||||
| Address1: | 10 LAKE DR | ||||||||
| Address2: | |||||||||
| City: | BONNE TERRE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 636281820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733582800 | ||||||||
| FaxNumber: | 5733581090 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 03/21/2019 | ||||||||
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| AuthorizedOfficialLastName: | SHIRSHEKAN | ||||||||
| AuthorizedOfficialFirstName: | SHARO | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5737010600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 031997 | MO | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 103256004 | 05 | MO | MEDICAID |