Healthcare Provider Details

I. General information

NPI: 1225585714
Provider Name (Legal Business Name): GREENVILLE HEALTH CARE CENTER, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2016
Last Update Date: 09/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 SYCAMORE STREET
GREENVILLE MO
63944
US

IV. Provider business mailing address

1869 CRAIG PARK CT
SAINT LOUIS MO
63146-4122
US

V. Phone/Fax

Practice location:
  • Phone: 314-543-3800
  • Fax:
Mailing address:
  • Phone: 314-543-3805
  • Fax: 314-543-3880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberLC001502475
License Number StateMO

VIII. Authorized Official

Name: RICHARD J. DESTEFANE
Title or Position: PRESIDENT
Credential:
Phone: 314-543-3800