Healthcare Provider Details

I. General information

NPI: 1104235548
Provider Name (Legal Business Name): GARDEN VILLAS OF SOUTH COUNTY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2014
Last Update Date: 08/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13457 TESSON FERRY RD
SAINT LOUIS MO
63128-4010
US

IV. Provider business mailing address

14805 N OUTER 40 RD SUITE 300
CHESTERFIELD MO
63017-6060
US

V. Phone/Fax

Practice location:
  • Phone: 314-843-7788
  • Fax: 314-843-7845
Mailing address:
  • Phone: 636-733-7000
  • Fax: 636-733-7010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number041921
License Number StateMO

VIII. Authorized Official

Name: MR. GAIL LEE HARTMANN
Title or Position: TREASURER
Credential:
Phone: 636-733-7000