Provider Demographics
NPI:1073693826
Name:FIESER NURSING CENTER LLC
Entity Type:Organization
Organization Name:FIESER NURSING CENTER LLC
Other - Org Name:FIESER NURSING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:E
Authorized Official - Last Name:FIESER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-343-4344
Mailing Address - Street 1:404 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026
Mailing Address - Country:US
Mailing Address - Phone:636-343-4344
Mailing Address - Fax:636-349-4536
Practice Address - Street 1:404 MAIN STREET
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026
Practice Address - Country:US
Practice Address - Phone:636-343-4344
Practice Address - Fax:636-349-4536
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO032681313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO26A490Medicaid