Healthcare Provider Details

I. General information

NPI: 1093710824
Provider Name (Legal Business Name): ROSEWOOD CARE CENTER OF ST LOUIS COUNTY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2005
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11278 SCHUETZ RD
SAINT LOUIS MO
63146-4957
US

IV. Provider business mailing address

11701 BORMAN DR STE 315
SAINT LOUIS MO
63146-4194
US

V. Phone/Fax

Practice location:
  • Phone: 314-991-4066
  • Fax:
Mailing address:
  • Phone: 314-994-9070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number1303580001
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number031124
License Number StateMO

VIII. Authorized Official

Name: LARRY VANDER MATEN
Title or Position: PRESIDENT
Credential:
Phone: 314-994-9070