Healthcare Provider Details

I. General information

NPI: 1447719059
Provider Name (Legal Business Name): SIRO OP ROYAL OAK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2019
Last Update Date: 03/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4960 LACLEDE AVE
SAINT LOUIS MO
63108-1404
US

IV. Provider business mailing address

22 HERRICK DR
LAWRENCE NY
11559-1528
US

V. Phone/Fax

Practice location:
  • Phone: 314-361-6240
  • Fax: 314-361-6682
Mailing address:
  • Phone: 516-727-1634
  • Fax:

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: SAMUEL GOLDNER
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 516-727-1634