Healthcare Provider Details

I. General information

NPI: 1568614063
Provider Name (Legal Business Name): VICTORIAN MANOR OF ST CLAIR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2008
Last Update Date: 10/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 CHARLES DR
ST CLAIR MO
63077
US

IV. Provider business mailing address

1015 SPRINGFIELD RD
OWENSVILLE MO
65066-1015
US

V. Phone/Fax

Practice location:
  • Phone: 636-322-0003
  • Fax: 636-322-0006
Mailing address:
  • Phone: 573-437-2103
  • Fax: 573-437-2219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number036029
License Number StateMO

VIII. Authorized Official

Name: NANCY L QUICK
Title or Position: SECRETARY
Credential:
Phone: 573-437-2103