Provider Demographics
NPI:1063730869
Name:JOHN ROBERT REITER RESIDENTIAL CARE
Entity type:Organization
Organization Name:JOHN ROBERT REITER RESIDENTIAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:REITER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-497-6331
Mailing Address - Street 1:5415 THEKLA AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63120-2513
Mailing Address - Country:US
Mailing Address - Phone:314-385-8180
Mailing Address - Fax:314-385-8880
Practice Address - Street 1:5415 THEKLA AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63120-2513
Practice Address - Country:US
Practice Address - Phone:314-385-8180
Practice Address - Fax:314-385-8880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-04
Last Update Date:2010-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO037959310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1407058894Medicaid