Healthcare Provider Details

I. General information

NPI: 1164826004
Provider Name (Legal Business Name): THE ESTATES OF PERRYVILLE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2014
Last Update Date: 10/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 N WEST ST
PERRYVILLE MO
63775-1359
US

IV. Provider business mailing address

2917 W GREENLEAF AVE
CHICAGO IL
60645-2915
US

V. Phone/Fax

Practice location:
  • Phone: 573-547-1011
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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: TUVIYAH SPECTOR
Title or Position: MANAGING MEMBER
Credential:
Phone: 773-322-0387