Healthcare Provider Details

I. General information

NPI: 1548061310
Provider Name (Legal Business Name): PINE GROVE MANOR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2025
Last Update Date: 03/19/2025
Certification Date: 03/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4359 TAFT AVE
SAINT LOUIS MO
63116-1533
US

IV. Provider business mailing address

4359 TAFT AVE
SAINT LOUIS MO
63116-1533
US

V. Phone/Fax

Practice location:
  • Phone: 314-752-2022
  • Fax:
Mailing address:
  • Phone:
  • 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: MR. DAVID GARETZ
Title or Position: CFO
Credential:
Phone: 323-987-5954