Healthcare Provider Details

I. General information

NPI: 1114993391
Provider Name (Legal Business Name): BETHESDA LONG TERM CARE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 05/28/2025
Certification Date: 05/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9645 BIG BEND BLVD
SAINT LOUIS MO
63122-6521
US

IV. Provider business mailing address

12101 WOODCREST EXECUTIVE DR STE 200
SAINT LOUIS MO
63141-5047
US

V. Phone/Fax

Practice location:
  • Phone: 314-968-5460
  • Fax: 314-800-1961
Mailing address:
  • Phone: 314-800-1900
  • Fax: 314-900-3683

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number031349
License Number StateMO

VIII. Authorized Official

Name: ROGER BYRNE
Title or Position: CFO
Credential:
Phone: 314-800-1955