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NPI Code Detail

MEDICARE: CREVE COEUR MANOR LLC

MEDICARE: CREVE COEUR MANOR LLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1314000000XSkilled Nursing Facility031651MO

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1194806109
Entity Type Code : Organization
Provider Name (Legal Business Name) : CREVE COEUR MANOR LLC
Provider Business Mailing Address
First Line : 1127 TIMBER RUN DR
Second Line :
City : SAINT LOUIS
State : MO
Zip : 63146-4482
Country : US
Telephone Number : 314-434-8361
Fax Number : 314-434-7785
Provider Business Practice Location Address
First Line : 1127 TIMBER RUN DR
Second Line :
City : SAINT LOUIS
State : MO
Zip : 63146-4482
Country : US
Telephone Number : 314-434-8361
Fax Number : 314-434-7785
Authorized Official
Title or Position : MANAGING MEMBER
Name : SHARO SHIRSHEKAN
Credential :
Telephone Number : 573-701-0600
Provider Enumeration Date : 10/17/2006
Last Update Date : 12/17/2013

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Directions to “CREVE COEUR MANOR LLC ” Practice Location

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