=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679901482
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CPLACE ST CHARLES SNF LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/15/2013
-----------------------------------------------------
Last Update Date | 02/13/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2150 W RANDOLPH ST
-----------------------------------------------------
City | SAINT CHARLES
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63301-0844
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-946-4966
-----------------------------------------------------
Fax | 636-916-3386
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 310 10TH AVE N
-----------------------------------------------------
City | SAFETY HARBOR
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34695-3416
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-797-5200
-----------------------------------------------------
Fax | 727-797-3807
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | MS. LYNDA S HEBBELN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 727-797-5200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------