Provider Demographics
NPI:1831216589
Name:FOUNTAINBLEAU OF CAPE GIRARDEAU, INC.
Entity type:Organization
Organization Name:FOUNTAINBLEAU OF CAPE GIRARDEAU, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SHAFIQ
Authorized Official - Middle Name:M
Authorized Official - Last Name:MALIK
Authorized Official - Suffix:
Authorized Official - Credentials:PRESIDENT
Authorized Official - Phone:573-335-1999
Mailing Address - Street 1:2001 N KINGSHIGHWAY ST
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-2127
Mailing Address - Country:US
Mailing Address - Phone:573-335-1999
Mailing Address - Fax:573-335-1997
Practice Address - Street 1:2001 N KINGSHIGHWAY ST
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-2127
Practice Address - Country:US
Practice Address - Phone:573-335-1999
Practice Address - Fax:573-335-1997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO032007310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility