Healthcare Provider Details

I. General information

NPI: 1649312745
Provider Name (Legal Business Name): SOUTH COUNTY NURSING HOME, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 10/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 W OUTER 21 RD
ARNOLD MO
63010-4644
US

IV. Provider business mailing address

1101 W OUTER 21 RD
ARNOLD MO
63010-4644
US

V. Phone/Fax

Practice location:
  • Phone: 636-296-5455
  • Fax: 636-296-5086
Mailing address:
  • Phone: 636-296-5455
  • Fax: 636-296-5086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number031860
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number44219300001
License Number StateMO

VIII. Authorized Official

Name: MRS. SAWSAN MAKHAMREH
Title or Position: ADMINISTRATOR
Credential:
Phone: 636-296-5455