Healthcare Provider Details

I. General information

NPI: 1831057587
Provider Name (Legal Business Name): MISSOURI ONE OPCO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2026
Last Update Date: 01/12/2026
Certification Date: 01/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10954 KENNERLY RD
SAINT LOUIS MO
63128-2018
US

IV. Provider business mailing address

10954 KENNERLY RD
SAINT LOUIS MO
63128-2018
US

V. Phone/Fax

Practice location:
  • Phone: 314-843-4242
  • Fax: 314-843-4031
Mailing address:
  • Phone: 314-843-4242
  • Fax: 314-843-4031

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: MENACHEM KOFMAN
Title or Position: MANAGER
Credential:
Phone: 917-533-4361