Healthcare Provider Details

I. General information

NPI: 1538659297
Provider Name (Legal Business Name): SRZ OP FRONTIER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2018
Last Update Date: 05/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2840 W CLAY ST
SAINT CHARLES MO
63301-2536
US

IV. Provider business mailing address

22 HERRICK DR
LAWRENCE NY
11559-1528
US

V. Phone/Fax

Practice location:
  • Phone: 636-946-6100
  • Fax:
Mailing address:
  • Phone: 929-928-0307
  • 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 PERSON/OFFICIAL
Credential:
Phone: 347-677-0448