Provider Demographics
NPI:1194864447
Name:GLENDALE ASSISTED LIVING
Entity Type:Organization
Organization Name:GLENDALE ASSISTED LIVING
Other - Org Name:FREDERICK ST MANOR MAPLE CREST MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:A
Authorized Official - Last Name:COMPTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-334-2662
Mailing Address - Street 1:430 N FREDERICK
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701
Mailing Address - Country:US
Mailing Address - Phone:573-334-2662
Mailing Address - Fax:573-339-7541
Practice Address - Street 1:430 N FREDERICK
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701
Practice Address - Country:US
Practice Address - Phone:573-334-2662
Practice Address - Fax:573-339-7541
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility