Provider Demographics
NPI:1821258443
Name:CORI MANOR HEALTHCARE & REHABILITATION CENTER, LLC
Entity Type:Organization
Organization Name:CORI MANOR HEALTHCARE & REHABILITATION CENTER, LLC
Other - Org Name:CORI MANOR HEALTHCARE & REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MAKHLOUF
Authorized Official - Middle Name:
Authorized Official - Last Name:SUISSA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-963-7570
Mailing Address - Street 1:560 CORISANDE HILLS RD
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026-5613
Mailing Address - Country:US
Mailing Address - Phone:636-343-2282
Mailing Address - Fax:
Practice Address - Street 1:560 CORISANDE HILLS RD
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-5613
Practice Address - Country:US
Practice Address - Phone:636-343-2282
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-17
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO035712314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO102744604Medicaid
MO102744604Medicaid
265395Medicare Oscar/Certification