Provider Demographics
NPI:1598828774
Name:MARYMOUNT MANOR LLC
Entity Type:Organization
Organization Name:MARYMOUNT MANOR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMEBER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:J
Authorized Official - Last Name:RILEY
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:636-349-2311
Mailing Address - Street 1:1749 GILSINN LN
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026-2003
Mailing Address - Country:US
Mailing Address - Phone:636-349-2311
Mailing Address - Fax:636-349-6491
Practice Address - Street 1:313 AUGUSTINE RD
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:MO
Practice Address - Zip Code:63025-1935
Practice Address - Country:US
Practice Address - Phone:636-938-6770
Practice Address - Fax:636-938-3742
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility