Healthcare Provider Details

I. General information

NPI: 1053247627
Provider Name (Legal Business Name): CEDARGATE OPCO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2026
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2350 KANELL BLVD
POPLAR BLUFF MO
63901-4036
US

IV. Provider business mailing address

1869 CRAIG PARK CT
SAINT LOUIS MO
63146-4122
US

V. Phone/Fax

Practice location:
  • Phone: 573-785-0188
  • Fax: 573-785-7321
Mailing address:
  • Phone: 314-543-3800
  • Fax: 314-543-3800

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: NICHOLAS DESTEFANE
Title or Position: PRESIDENT
Credential:
Phone: 314-543-3800