Provider Demographics
NPI:1477544104
Name:FRIENDSHIP VILLAGE OF SOUTH COUNTY
Entity Type:Organization
Organization Name:FRIENDSHIP VILLAGE OF SOUTH COUNTY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SUE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAMPION
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-842-6840
Mailing Address - Street 1:12651 VILLAGE CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63127-1778
Mailing Address - Country:US
Mailing Address - Phone:314-842-6840
Mailing Address - Fax:314-525-7500
Practice Address - Street 1:12651 VILLAGE CIRCLE DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63127-1778
Practice Address - Country:US
Practice Address - Phone:314-842-6840
Practice Address - Fax:314-525-7500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-02
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO030527310400000X
MO030733314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO101486504Medicaid
MO101486504Medicaid