Healthcare Provider Details

I. General information

NPI: 1205859105
Provider Name (Legal Business Name): VILLAGE NORTH, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 03/23/2021
Certification Date: 03/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11160 VILLAGE NORTH DR
SAINT LOUIS MO
63136-6159
US

IV. Provider business mailing address

11133 DUNN RD PFD 2ND FLOOR SUITE 2179
SAINT LOUIS MO
63136-6119
US

V. Phone/Fax

Practice location:
  • Phone: 314-355-8010
  • Fax: 314-653-4801
Mailing address:
  • Phone: 314-653-4093
  • Fax: 314-653-4077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number030933
License Number StateMO

VIII. Authorized Official

Name: MR. DANIEL ROTHERY
Title or Position: OFFICER
Credential:
Phone: 314-273-0791