Basic Information
| Provider Information | |||||||||
| NPI: | 1205859105 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VILLAGE NORTH, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | VILLAGE NORTH REHABILITATION AND NURSING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11133 DUNN RD | ||||||||
| Address2: | PFD 2ND FLOOR SUITE 2179 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631366119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3146534093 | ||||||||
| FaxNumber: | 3146534077 | ||||||||
| Practice Location | |||||||||
| Address1: | 11160 VILLAGE NORTH DR | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631366159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143558010 | ||||||||
| FaxNumber: | 3146534801 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 03/23/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROTHERY | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3142730791 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 030933 | MO | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 36044 | 01 | GHP | OTHER | 101863405 | 05 | MO | MEDICAID | 138311 | 01 | HEALTH LINK | OTHER | 195321 | 01 | BLUE CROSS BLUE SHIELD | OTHER | 7101115 | 01 | UNITED HEALTHCARE | OTHER |