MEDICARE: SOUTH COUNTY 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
1	314000000X	Skilled Nursing Facility

General Provider Information

NPI Number	:	1881520310
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH COUNTY 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	:	314-543-3800
Fax Number	:	314-543-3800

Provider Business Practice Location Address
First Line	:	1101 W OUTER 21 RD
Second Line	:
City	:	ARNOLD
State	:	MO
Zip	:	63010-4644
Country	:	US
Telephone Number	:	636-296-5455
Fax Number	:	636-296-5086

Authorized Official
Title or Position	:	PRESIDENT
Name	:	NICHOLAS DESTEFANE
Credential	:
Telephone Number	:	314-543-3800

Provider Enumeration Date	:	06/22/2026
Last Update Date	:	06/22/2026

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