Provider Demographics
NPI:1104310804
Name:MC FREMONT HEALTHCARE, LLC
Entity type:Organization
Organization Name:MC FREMONT HEALTHCARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JUDAH
Authorized Official - Middle Name:
Authorized Official - Last Name:BIENSTOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-631-3000
Mailing Address - Street 1:477 N LINDBERGH BLVD STE 310
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-7856
Mailing Address - Country:US
Mailing Address - Phone:131-463-1300
Mailing Address - Fax:
Practice Address - Street 1:2915 S FREMONT AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-3608
Practice Address - Country:US
Practice Address - Phone:417-883-4022
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-18
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility