Provider Demographics
NPI:1477670008
Name:PARC PROVENCE MANAGEMENT, L.L.C.
Entity Type:Organization
Organization Name:PARC PROVENCE MANAGEMENT, L.L.C.
Other - Org Name:PARC PROVENCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARCIA
Authorized Official - Middle Name:
Authorized Official - Last Name:AZAR
Authorized Official - Suffix:
Authorized Official - Credentials:RN, LNHA
Authorized Official - Phone:314-542-2500
Mailing Address - Street 1:605 COEUR DE VILLE DR
Mailing Address - Street 2:
Mailing Address - City:CREVE COEUR
Mailing Address - State:MO
Mailing Address - Zip Code:63141-6603
Mailing Address - Country:US
Mailing Address - Phone:314-542-2500
Mailing Address - Fax:314-453-7840
Practice Address - Street 1:605 COEUR DE VILLE DR
Practice Address - Street 2:
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-6603
Practice Address - Country:US
Practice Address - Phone:314-542-2500
Practice Address - Fax:314-453-7840
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO032612314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO032612OtherSNF LICENSE NO.
MO106129406OtherPROVIDER NUMBER
MO24122AOtherFACILITY NUMBER