Provider Demographics
NPI:1093760886
Name:SENIORTRUST OF CHARLEVOIX, LLC
Entity Type:Organization
Organization Name:SENIORTRUST OF CHARLEVOIX, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:WEBB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-893-2749
Mailing Address - Street 1:1221 BOONES LICK RD
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63301-2328
Mailing Address - Country:US
Mailing Address - Phone:636-946-6140
Mailing Address - Fax:
Practice Address - Street 1:1221 BOONES LICK RD
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63301-2328
Practice Address - Country:US
Practice Address - Phone:636-946-6140
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO031526314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO155063OtherBC BS MO
229216OtherGHP ADVANTRA
265160OtherMERCY
7100076OtherUNITED HEALTH CARE
MO155063OtherBC BS MO