Basic Information
| Provider Information | |||||||||
| NPI: | 1326217217 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BEAUVAIS MANOR HEALTHCARE & REHAB CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7434 SKOKIE BLVD | ||||||||
| Address2: | |||||||||
| City: | SKOKIE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600773341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8479822300 | ||||||||
| FaxNumber: | 8479822304 | ||||||||
| Practice Location | |||||||||
| Address1: | 3625 MAGNOLIA AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631104048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3147712990 | ||||||||
| FaxNumber: | 3147717960 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/25/2008 | ||||||||
| LastUpdateDate: | 07/30/2008 | ||||||||
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| AuthorizedOfficialLastName: | WOLFE | ||||||||
| AuthorizedOfficialFirstName: | SHELDON | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 8479822300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | MO | N | Nursing & Custodial Care Facilities | Skilled Nursing Facility | 314000000X | 035624 | MO | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 108680109 | 05 | MO | MEDICAID |