=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013195478
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UNION MANOR RESIDENTIAL CARE FACILITY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2008
-----------------------------------------------------
Last Update Date | 02/07/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2711 UNION BLVD
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63113-1003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-383-7310
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2711 UNION BLVD
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63113-1003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-383-7310
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FACILITY OWNER
-----------------------------------------------------
Name | MRS. ALMA COOK
-----------------------------------------------------
Credential | CNA, L1MA
-----------------------------------------------------
Telephone | 314-361-1792
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 034758
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------