Healthcare Provider Details

I. General information

NPI: 1780679555
Provider Name (Legal Business Name): CATHEDRAL GARDENS CARE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 REDMAN RD
SAINT LOUIS MO
63136-5863
US

IV. Provider business mailing address

2600 REDMAN RD
SAINT LOUIS MO
63136-5863
US

V. Phone/Fax

Practice location:
  • Phone: 314-355-8585
  • Fax: 314-355-4645
Mailing address:
  • Phone: 314-355-8585
  • Fax: 314-355-4645

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number031388
License Number StateMO

VIII. Authorized Official

Name: ALICE CHUKUKERE
Title or Position: MDS COORDINATOR
Credential: L.P.N.
Phone: 314-355-8585