=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285752899
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FOUNTAINBLEAU NURSING CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1349 US HIGHWAY 61
-----------------------------------------------------
City | FESTUS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63028-4107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-937-3500
-----------------------------------------------------
Fax | 636-931-2646
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2732 BLOOMFIELD RD
-----------------------------------------------------
City | CAPE GIRARDEAU
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63703-6302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-335-3044
-----------------------------------------------------
Fax | 573-335-6724
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. SHAFIQ M MALIK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 573-335-3044
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | 032222
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------