Healthcare Provider Details

I. General information

NPI: 1790789204
Provider Name (Legal Business Name): DUTCHTOWN CARE CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2005
Last Update Date: 06/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3421 GASCONADE ST
SAINT LOUIS MO
63118-4201
US

IV. Provider business mailing address

3421 GASCONADE ST
SAINT LOUIS MO
63118-4201
US

V. Phone/Fax

Practice location:
  • Phone: 314-832-4700
  • Fax: 314-832-7177
Mailing address:
  • Phone: 314-832-4700
  • Fax: 314-832-7177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number030951
License Number StateMO

VIII. Authorized Official

Name: MS. LILY LANDY
Title or Position: ADMINISTRATOR
Credential:
Phone: 314-832-4700