Healthcare Provider Details

I. General information

NPI: 1902803232
Provider Name (Legal Business Name): ELDERCARE OF MARBLE HILL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2005
Last Update Date: 12/01/2020
Certification Date: 12/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 HIGHWAY 34 W
MARBLE HILL MO
63764-4301
US

IV. Provider business mailing address

702 HIGHWAY 34 W
MARBLE HILL MO
63764-4301
US

V. Phone/Fax

Practice location:
  • Phone: 573-238-2614
  • Fax: 573-238-9835
Mailing address:
  • Phone: 636-477-3280
  • Fax: 636-477-3241

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. MARK LIERMAN
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 636-477-3280