Healthcare Provider Details

I. General information

NPI: 1194806109
Provider Name (Legal Business Name): CREVE COEUR MANOR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 12/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1127 TIMBER RUN DR
SAINT LOUIS MO
63146-4482
US

IV. Provider business mailing address

1127 TIMBER RUN DR
SAINT LOUIS MO
63146-4482
US

V. Phone/Fax

Practice location:
  • Phone: 314-434-8361
  • Fax: 314-434-7785
Mailing address:
  • Phone: 314-434-8361
  • Fax: 314-434-7785

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number031651
License Number StateMO

VIII. Authorized Official

Name: SHARO SHIRSHEKAN
Title or Position: MANAGING MEMBER
Credential:
Phone: 573-701-0600