Provider Demographics
NPI:1962531079
Name:WINGHAVENLLC
Entity type:Organization
Organization Name:WINGHAVENLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:B
Authorized Official - Last Name:GAMMON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:636-625-2950
Mailing Address - Street 1:2002 BOARDWALK PLACE DR
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-3900
Mailing Address - Country:US
Mailing Address - Phone:636-561-7275
Mailing Address - Fax:636-561-5304
Practice Address - Street 1:2002 BOARDWALK PLACE DR
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-3900
Practice Address - Country:US
Practice Address - Phone:636-561-7275
Practice Address - Fax:636-561-5304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility