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General NPI Number Information
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NPI Number | 1962531079
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Entity Type | Organization
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Legal Business Name | WINGHAVENLLC
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Dates
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Enumeration Date | 03/05/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 2002 BOARDWALK PLACE DR
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City | O FALLON
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State | MO
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Zip | 63368-3900
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Country | US
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Telephone | 636-561-7275
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Fax | 636-561-5304
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Provider Business Mailing Address
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Address Line | 2002 BOARDWALK PLACE DR
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City | O FALLON
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State | MO
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Zip | 63368-3900
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Country | US
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Telephone | 636-561-7275
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Fax | 636-561-5304
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Authorized Official
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Title or Position | GENERAL MANAGER
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Name | MR. JOHN B GAMMON JR.
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Credential |
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Telephone | 636-625-2950
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number |
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License Number State |
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