Healthcare Provider Details

I. General information

NPI: 1467378661
Provider Name (Legal Business Name): HIDDEN LAKE AL OPCO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2026
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11728 HIDDEN LAKE DR
SAINT LOUIS MO
63138-1765
US

IV. Provider business mailing address

1869 CRAIG PARK CT
SAINT LOUIS MO
63146-4122
US

V. Phone/Fax

Practice location:
  • Phone: 314-355-8833
  • Fax: 314-736-1098
Mailing address:
  • Phone: 314-543-3800
  • Fax: 314-543-3800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

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