MEDICARE: SOUTH COUNTY NURSING HOME, INC.

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	332BP3500X	Parenteral & Enteral Nutrition Supplies (DME)	44219300001	MO
2	314000000X	Skilled Nursing Facility	031860	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1649312745
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH COUNTY NURSING HOME, INC.

Provider Business Mailing Address
First Line	:	1101 W OUTER 21 RD
Second Line	:
City	:	ARNOLD
State	:	MO
Zip	:	63010-4644
Country	:	US
Telephone Number	:	636-296-5455
Fax Number	:	636-296-5086

Provider Business Practice Location Address
First Line	:	1101 W OUTER 21 RD
Second Line	:
City	:	ARNOLD
State	:	MO
Zip	:	63010-4644
Country	:	US
Telephone Number	:	636-296-5455
Fax Number	:	636-296-5086

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MRS. SAWSAN MAKHAMREH
Credential	:
Telephone Number	:	636-296-5455

Provider Enumeration Date	:	02/13/2007
Last Update Date	:	10/21/2011

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