=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265420079
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JEWISH CENTER FOR AGED
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/06/2005
-----------------------------------------------------
Last Update Date | 09/12/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13190 S OUTER 40
-----------------------------------------------------
City | CHESTERFIELD
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63017-5917
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-434-3330
-----------------------------------------------------
Fax | 314-392-6286
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13190 S OUTER 40
-----------------------------------------------------
City | CHESTERFIELD
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63017-5917
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-434-3330
-----------------------------------------------------
Fax | 314-392-6286
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CONTROLLER
-----------------------------------------------------
Name | MR. JOHN BARROW
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 314-434-3330
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 031593
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------