Healthcare Provider Details

I. General information

NPI: 1407888407
Provider Name (Legal Business Name): BERTHOLD NURSING CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 01/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6637 BERTHOLD AVE
SAINT LOUIS MO
63139-3318
US

IV. Provider business mailing address

731 N MAIN ST P.O. BOX 1210
SIKESTON MO
63801-2151
US

V. Phone/Fax

Practice location:
  • Phone: 314-781-3444
  • Fax: 314-781-6139
Mailing address:
  • Phone: 573-471-1276
  • Fax: 573-472-8504

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number040704
License Number StateMO

VIII. Authorized Official

Name: CLIFF SHIRRELL
Title or Position: VICE PRESIDENT
Credential:
Phone: 573-471-1276