Provider Demographics
NPI:1093710824
Name:ROSEWOOD CARE CENTER OF ST LOUIS COUNTY, INC
Entity Type:Organization
Organization Name:ROSEWOOD CARE CENTER OF ST LOUIS COUNTY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:VANDER MATEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-994-9070
Mailing Address - Street 1:11701 BORMAN DR
Mailing Address - Street 2:STE 315
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-4194
Mailing Address - Country:US
Mailing Address - Phone:314-994-9070
Mailing Address - Fax:
Practice Address - Street 1:11278 SCHUETZ RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63146-4957
Practice Address - Country:US
Practice Address - Phone:314-991-4066
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-17
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO031124314000000X
IL1303580001332BP3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO=========001Medicaid
MO1303580001Medicare NSC
MO=========001Medicaid