Provider Demographics
NPI:1235127069
Name:CHARITON PARK HEALTH CARE CENTER, LLC
Entity Type:Organization
Organization Name:CHARITON PARK HEALTH CARE CENTER, LLC
Other - Org Name:CHARITON PARK HEALTH CARE CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:ASHWIN
Authorized Official - Middle Name:
Authorized Official - Last Name:DUNDOO
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:314-543-3800
Mailing Address - Fax:314-543-3880
Practice Address - Street 1:902 MANOR DR
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MO
Practice Address - Zip Code:65281-1236
Practice Address - Country:US
Practice Address - Phone:660-388-6486
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-06
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO102561206Medicaid
MO102561206Medicaid