Basic Information
| Provider Information | |||||||||
| NPI: | 1629178686 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BEVO HEALTHCARE MANAGEMENT INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | BEAUVAIS MANOR ON THE PARK | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3625 MAGNOLIA AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631104048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3147712990 | ||||||||
| FaxNumber: | 3147717960 | ||||||||
| Practice Location | |||||||||
| Address1: | 3625 MAGNOLIA AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631104048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3147712990 | ||||||||
| FaxNumber: | 3147717960 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LANIER | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3147712990 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 031084 | MO | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.