Healthcare Provider Details

I. General information

NPI: 1629178686
Provider Name (Legal Business Name): BEVO HEALTHCARE MANAGEMENT INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3625 MAGNOLIA AVE
SAINT LOUIS MO
63110-4048
US

IV. Provider business mailing address

3625 MAGNOLIA AVE
SAINT LOUIS MO
63110-4048
US

V. Phone/Fax

Practice location:
  • Phone: 314-771-2990
  • Fax: 314-771-7960
Mailing address:
  • Phone: 314-771-2990
  • Fax: 314-771-7960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number031084
License Number StateMO

VIII. Authorized Official

Name: MARK D LANIER
Title or Position: CFO
Credential:
Phone: 314-771-2990