Provider Demographics
NPI:1588871701
Name:MARY RYDER HOME
Entity type:Organization
Organization Name:MARY RYDER HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:STEFANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:OSIEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-531-2981
Mailing Address - Street 1:4361 OLIVE ST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108-2621
Mailing Address - Country:US
Mailing Address - Phone:314-531-2981
Mailing Address - Fax:314-531-2990
Practice Address - Street 1:4361 OLIVE ST
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-2621
Practice Address - Country:US
Practice Address - Phone:314-531-2981
Practice Address - Fax:314-531-2990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 253Z00000X
MO032674313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care FacilityGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO266740513Medicaid