Provider Demographics
NPI:1851467039
Name:ALEXIAN BROTHERS SHERBROOKE VILLAGE
Entity Type:Organization
Organization Name:ALEXIAN BROTHERS SHERBROOKE VILLAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AR DIRECTOR, ALEXIAN BROS SR MIN
Authorized Official - Prefix:
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:SEELBACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-880-8938
Mailing Address - Street 1:4005 RIPA AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63125-2378
Mailing Address - Country:US
Mailing Address - Phone:314-544-1111
Mailing Address - Fax:
Practice Address - Street 1:4005 RIPA AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63125-2378
Practice Address - Country:US
Practice Address - Phone:314-544-1111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2012-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
128655OtherBLUE CROSS
MO102781804Medicaid
MO265417Medicare Oscar/Certification