Healthcare Provider Details

I. General information

NPI: 1215782149
Provider Name (Legal Business Name): GRAND MANOR HEALTH CARE CENTER, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2024
Last Update Date: 04/23/2024
Certification Date: 04/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3645 COOK AVE
SAINT LOUIS MO
63113-3801
US

IV. Provider business mailing address

1869 CRAIG PARK CT
SAINT LOUIS MO
63146-4122
US

V. Phone/Fax

Practice location:
  • Phone: 314-531-2352
  • Fax:
Mailing address:
  • Phone: 314-543-3816
  • Fax: 314-226-1736

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: MR. RICHARD J. DESTEFANE
Title or Position: PRESIDENT
Credential:
Phone: 314-543-3816