Provider Demographics
NPI:1225585714
Name:GREENVILLE HEALTH CARE CENTER, L.L.C.
Entity Type:Organization
Organization Name:GREENVILLE HEALTH CARE CENTER, L.L.C.
Other - Org Name:GREENVILLE HEALTH CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:DESTEFANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-543-3800
Mailing Address - Street 1:1869 CRAIG PARK CT
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-4122
Mailing Address - Country:US
Mailing Address - Phone:314-543-3805
Mailing Address - Fax:314-543-3880
Practice Address - Street 1:117 SYCAMORE STREET
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MO
Practice Address - Zip Code:63944
Practice Address - Country:US
Practice Address - Phone:314-543-3800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOLC001502475314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility