Healthcare Provider Details

I. General information

NPI: 1265420079
Provider Name (Legal Business Name): JEWISH CENTER FOR AGED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2005
Last Update Date: 09/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13190 S OUTER 40
CHESTERFIELD MO
63017-5917
US

IV. Provider business mailing address

13190 S OUTER 40
CHESTERFIELD MO
63017-5917
US

V. Phone/Fax

Practice location:
  • Phone: 314-434-3330
  • Fax: 314-392-6286
Mailing address:
  • Phone: 314-434-3330
  • Fax: 314-392-6286

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number031593
License Number StateMO

VIII. Authorized Official

Name: MR. JOHN BARROW
Title or Position: CONTROLLER
Credential:
Phone: 314-434-3330