Healthcare Provider Details

I. General information

NPI: 1912453986
Provider Name (Legal Business Name): PORTAGEVILLE HEALTH CARE CENTER, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2016
Last Update Date: 08/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

290 W STATE HIGHWAY 162
PORTAGEVILLE MO
63873-9397
US

IV. Provider business mailing address

1869 CRAIG PARK CT
SAINT LOUIS MO
63146-4122
US

V. Phone/Fax

Practice location:
  • Phone: 573-379-2017
  • Fax: 573-379-2735
Mailing address:
  • Phone: 314-543-3816
  • Fax: 314-543-3880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberLC001502456
License Number StateMO

VIII. Authorized Official

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