Healthcare Provider Details

I. General information

NPI: 1891024691
Provider Name (Legal Business Name): NORTHEASTERN NURSING & REHABILITATION CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2009
Last Update Date: 03/01/2010
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

1625 S 6TH ST
SPRINGFIELD IL
62703-2828
US

V. Phone/Fax

Practice location:
  • Phone: 314-355-8585
  • Fax: 314-355-4645
Mailing address:
  • Phone: 217-528-2244
  • Fax: 217-528-3412

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. ROBERT G HEDGES
Title or Position: MANAGING MEMBER OF LLC
Credential:
Phone: 217-528-2244