Provider Demographics
NPI:1245293182
Name:ST. ELIZABETH CARE CENTER, INC.
Entity type:Organization
Organization Name:ST. ELIZABETH CARE CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:DOERHOFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-493-2215
Mailing Address - Street 1:649 S WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:ST ELIZABETH
Mailing Address - State:MO
Mailing Address - Zip Code:65075-2440
Mailing Address - Country:US
Mailing Address - Phone:573-493-2215
Mailing Address - Fax:573-493-2712
Practice Address - Street 1:649 S WALNUT ST
Practice Address - Street 2:
Practice Address - City:ST ELIZABETH
Practice Address - State:MO
Practice Address - Zip Code:65075-2440
Practice Address - Country:US
Practice Address - Phone:573-493-2215
Practice Address - Fax:573-493-2712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-11
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO031788314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO265676Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER