Provider Demographics
NPI:1417662370
Name:JACKSON MANOR HEALTHCARE, LLC
Entity Type:Organization
Organization Name:JACKSON MANOR HEALTHCARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JUDAH
Authorized Official - Middle Name:
Authorized Official - Last Name:BIENSTOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-631-3000
Mailing Address - Street 1:477 N LINDBERGH BLVD STE 310
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-7856
Mailing Address - Country:US
Mailing Address - Phone:314-631-3000
Mailing Address - Fax:
Practice Address - Street 1:710 BROADRIDGE DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MO
Practice Address - Zip Code:63755-3042
Practice Address - Country:US
Practice Address - Phone:573-243-3101
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-16
Last Update Date:2023-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility