Healthcare Provider Details

I. General information

NPI: 1144301144
Provider Name (Legal Business Name): ST JOE MANOR INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 03/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 LAKE DR
BONNE TERRE MO
63628-1820
US

IV. Provider business mailing address

10 LAKE DR
BONNE TERRE MO
63628-1820
US

V. Phone/Fax

Practice location:
  • Phone: 573-358-2800
  • Fax: 573-358-1090
Mailing address:
  • Phone: 573-358-2800
  • Fax: 573-358-1090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number031997
License Number StateMO

VIII. Authorized Official

Name: SHARO SHIRSHEKAN
Title or Position: PRESIDENT
Credential:
Phone: 573-701-0600