Provider Demographics
NPI:1194765529
Name:GRAND MANOR NURSING & REHABILITATION CENTER, L.L.C.
Entity type:Organization
Organization Name:GRAND MANOR NURSING & REHABILITATION CENTER, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MAKHLOUF
Authorized Official - Middle Name:
Authorized Official - Last Name:SUISSA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-531-2352
Mailing Address - Street 1:3645 COOK AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63113-3801
Mailing Address - Country:US
Mailing Address - Phone:314-531-2352
Mailing Address - Fax:314-531-7140
Practice Address - Street 1:3645 COOK AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63113-3801
Practice Address - Country:US
Practice Address - Phone:314-531-2352
Practice Address - Fax:314-531-7140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-07
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO265717314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO265717Medicare ID - Type Unspecified