Healthcare Provider Details

I. General information

NPI: 1457412587
Provider Name (Legal Business Name): MARYMOUNT MANOR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 12/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

313 AUGUSTINE RD
EUREKA MO
63025-1935
US

IV. Provider business mailing address

1749 GILSINN LN
FENTON MO
63026-2003
US

V. Phone/Fax

Practice location:
  • Phone: 636-938-6770
  • Fax: 636-938-3742
Mailing address:
  • Phone: 636-349-2311
  • Fax: 636-349-6491

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. CHARLES J RILEY
Title or Position: MEMEBER
Credential:
Phone: 636-349-2311