Healthcare Provider Details

I. General information

NPI: 1194765529
Provider Name (Legal Business Name): GRAND MANOR NURSING & REHABILITATION CENTER, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 11/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3645 COOK AVE
SAINT LOUIS MO
63113-3801
US

IV. Provider business mailing address

3645 COOK AVE
SAINT LOUIS MO
63113-3801
US

V. Phone/Fax

Practice location:
  • Phone: 314-531-2352
  • Fax: 314-531-7140
Mailing address:
  • Phone: 314-531-2352
  • Fax: 314-531-7140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number265717
License Number StateMO

VIII. Authorized Official

Name: MAKHLOUF SUISSA
Title or Position: MEMBER
Credential:
Phone: 314-531-2352