=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538108469
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHVIEW VILLAGE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2006
-----------------------------------------------------
Last Update Date | 12/23/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2415 N KINGSHIGHWAY BLVD
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63113-1109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-361-1300
-----------------------------------------------------
Fax | 314-361-1374
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2415 N KINGSHIGHWAY BLVD
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63113-1109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-361-1300
-----------------------------------------------------
Fax | 314-361-1374
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MAKHLOUF SUISSA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 314-361-1300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 265524
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------