MEDICARE: DELMAR GARDENS NORTH OPERATING, 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
1	314000000X	Skilled Nursing Facility	031168	MO

Other Identifiers

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

General Provider Information

NPI Number	:	1750376612
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DELMAR GARDENS NORTH OPERATING, LLC

Provider Business Mailing Address
First Line	:	14805 N OUTER 40 RD
Second Line	:	SUITE 300
City	:	CHESTERFIELD
State	:	MO
Zip	:	63017-6060
Country	:	US
Telephone Number	:	636-733-7000
Fax Number	:	636-733-7010

Provider Business Practice Location Address
First Line	:	4401 PARKER RD
Second Line	:
City	:	BLACK JACK
State	:	MO
Zip	:	63033-4266
Country	:	US
Telephone Number	:	314-355-1516
Fax Number	:	314-355-9074

Authorized Official
Title or Position	:	TREASURER
Name	:	MR. GAIL LEE HARTMANN
Credential	:
Telephone Number	:	636-733-7000

Provider Enumeration Date	:	09/16/2005
Last Update Date	:	01/23/2015

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