Basic Information
| Provider Information | |||||||||
| NPI: | 1467072280 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EDGEWOOD MANOR HEALTH CARE CENTER, L.L.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1869 CRAIG PARK CT | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631464122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145433816 | ||||||||
| FaxNumber: | 3142261736 | ||||||||
| Practice Location | |||||||||
| Address1: | 11900 JESSICA LN | ||||||||
| Address2: | |||||||||
| City: | RAYTOWN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641382649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8163587858 | ||||||||
| FaxNumber: | 8163567775 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2020 | ||||||||
| LastUpdateDate: | 04/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | DESTEFANE | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3145433816 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.