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NPI Code Detail

MEDICARE: CANTON SNF OPCO LLC

MEDICARE: CANTON SNF OPCO 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 Facility

General Provider Information

NPI Number : 1205761079
Entity Type Code : Organization
Provider Name (Legal Business Name) : CANTON SNF OPCO LLC
Provider Business Mailing Address
First Line : 1869 CRAIG PARK CT
Second Line :
City : SAINT LOUIS
State : MO
Zip : 63146-4122
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 2714 13TH ST NW
Second Line :
City : CANTON
State : OH
Zip : 44708-3121
Country : US
Telephone Number : 330-456-2842
Fax Number :
Authorized Official
Title or Position : PRESIDENT
Name : NICHOLAS DESTEFANE
Credential :
Telephone Number : 314-543-3800
Provider Enumeration Date : 06/15/2026
Last Update Date : 06/15/2026

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Directions to “CANTON SNF OPCO LLC ” Practice Location

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