Healthcare Provider Details

I. General information

NPI: 1376433342
Provider Name (Legal Business Name): HIDDEN LAKE HEALTH CARE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2025
Last Update Date: 10/02/2025
Certification Date: 10/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11728 HIDDEN LAKE DR
SAINT LOUIS MO
63138-1765
US

IV. Provider business mailing address

1869 CRAIG PARK CT
SAINT LOUIS MO
63146-4122
US

V. Phone/Fax

Practice location:
  • Phone: 314-355-8833
  • Fax:
Mailing address:
  • Phone:
  • Fax: 314-226-1736

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: RICHARD J. DESTEFANE
Title or Position: PRESIDENT
Credential:
Phone: 314-543-3805