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NPI Code Detail

MEDICARE: CREVE COEUR MANOR HEALTH CARE CENTER LLC

MEDICARE: CREVE COEUR MANOR HEALTH CARE CENTER 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 : 1578419156
Entity Type Code : Organization
Provider Name (Legal Business Name) : CREVE COEUR MANOR HEALTH CARE CENTER 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 : 1127 TIMBER RUN DR
Second Line :
City : SAINT LOUIS
State : MO
Zip : 63146-4482
Country : US
Telephone Number : 314-434-8361
Fax Number :
Authorized Official
Title or Position : PRESIDENT
Name : RICHARD J. DESTEFANE
Credential :
Telephone Number : 314-543-3805
Provider Enumeration Date : 03/06/2026
Last Update Date : 03/06/2026

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