Provider Demographics
NPI:1104913391
Name:THI OF MISSOURI AT GRAVOIS, LLC
Entity type:Organization
Organization Name:THI OF MISSOURI AT GRAVOIS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHUETTLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-843-4242
Mailing Address - Street 1:920 RIDGEBROOK RD
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:MD
Mailing Address - Zip Code:21152-9390
Mailing Address - Country:US
Mailing Address - Phone:410-773-1000
Mailing Address - Fax:
Practice Address - Street 1:10954 KENNERLY RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2018
Practice Address - Country:US
Practice Address - Phone:314-843-4242
Practice Address - Fax:314-843-4031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-07
Last Update Date:2020-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO102809308Medicaid
265331Medicare Oscar/Certification