Provider Demographics
NPI:1629178686
Name:BEVO HEALTHCARE MANAGEMENT INC.
Entity type:Organization
Organization Name:BEVO HEALTHCARE MANAGEMENT INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:D
Authorized Official - Last Name:LANIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-771-2990
Mailing Address - Street 1:3625 MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-4048
Mailing Address - Country:US
Mailing Address - Phone:314-771-2990
Mailing Address - Fax:314-771-7960
Practice Address - Street 1:3625 MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-4048
Practice Address - Country:US
Practice Address - Phone:314-771-2990
Practice Address - Fax:314-771-7960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO031084314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
265699Medicare ID - Type UnspecifiedMEDICARE PROVIDER #