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General NPI Number Information
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NPI Number | 1578407656
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Entity Type | Organization
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Legal Business Name | PARK AVENUE SNF OPCO LLC
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Dates
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Enumeration Date | 04/17/2026
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Last Update Date | 08/13/2026
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Provider Practice Location Address
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Address Line | 146 PARK AVE
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City | ARLINGTON
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State | MA
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Zip | 02476-5829
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Country | US
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Telephone | 781-648-9530
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Fax |
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Provider Business Mailing Address
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Address Line | 1869 CRAIG PARK CT
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City | SAINT LOUIS
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State | MO
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Zip | 63146-4122
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Country | US
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Telephone | 314-543-3805
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | NICHOLAS DESTEFANE
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Credential |
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Telephone | 314-543-3800
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number |
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License Number State | NULL
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