MEDICARE: MOUNT VERNON AL OPCO LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1386579167
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOUNT VERNON AL OPCO LLC

Provider Business Mailing Address
First Line	:	1869 CRAIG PARK CT
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63146-4122
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1135 GAMBIER RD
Second Line	:
City	:	MOUNT VERNON
State	:	OH
Zip	:	43050-3839
Country	:	US
Telephone Number	:	740-392-1599
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	NICHOLAS DESTEFANE
Credential	:
Telephone Number	:	314-543-3800

Provider Enumeration Date	:	06/15/2026
Last Update Date	:	06/15/2026

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Directions to “MOUNT VERNON AL OPCO LLC ” Practice Location

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