Healthcare Provider Details

I. General information

NPI: 1407488703
Provider Name (Legal Business Name): THE ESTATES OF HIDDEN LAKE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2020
Last Update Date: 08/11/2025
Certification Date: 08/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11728 HIDDEN LAKE DR
ST. LOUIS MO
63138
US

IV. Provider business mailing address

11728 HIDDEN LAKE DR
ST. LOUIS MO
63138
US

V. Phone/Fax

Practice location:
  • Phone: 314-355-8833
  • Fax:
Mailing address:
  • Phone: 314-355-8833
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. LEVI ISRAEL
Title or Position: CEO
Credential:
Phone: 847-905-3000