Healthcare Provider Details

I. General information

NPI: 1245605211
Provider Name (Legal Business Name): KING CITY HEALTHCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2015
Last Update Date: 12/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W FAIRVIEW ST
KING CITY MO
64463-9606
US

IV. Provider business mailing address

6 CITYPLACE DR SUITE 430
SAINT LOUIS MO
63141-7157
US

V. Phone/Fax

Practice location:
  • Phone: 660-535-4325
  • Fax:
Mailing address:
  • Phone: 314-631-3000
  • Fax: 314-942-6634

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: JUDAH BIENSTOCK
Title or Position: MEMBER
Credential:
Phone: 314-631-3000