Basic Information
| Provider Information | |||||||||
| NPI: | 1194722439 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LADELLE INVESTMENT CO., INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ST. SOPHIA HEALTH & REHABILITATION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 473 N KIRKWOOD RD | ||||||||
| Address2: | |||||||||
| City: | KIRKWOOD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631223911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148217007 | ||||||||
| FaxNumber: | 3148217012 | ||||||||
| Practice Location | |||||||||
| Address1: | 936 CHARBONIER RD | ||||||||
| Address2: | |||||||||
| City: | FLORISSANT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630315220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148314800 | ||||||||
| FaxNumber: | 3148311310 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2005 | ||||||||
| LastUpdateDate: | 03/24/2014 | ||||||||
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| AuthorizedOfficialLastName: | MENOS | ||||||||
| AuthorizedOfficialFirstName: | DENNIS | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | CORPORATE SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 3148217007 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 028885 | MO | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 101495000 | 05 | MO | MEDICAID |