Provider Demographics
NPI:1902803232
Name:ELDERCARE OF MARBLE HILL, LLC
Entity Type:Organization
Organization Name:ELDERCARE OF MARBLE HILL, LLC
Other - Org Name:STONEBRIDGE MARBLE HILL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:LIERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-477-3280
Mailing Address - Street 1:702 HIGHWAY 34 W
Mailing Address - Street 2:
Mailing Address - City:MARBLE HILL
Mailing Address - State:MO
Mailing Address - Zip Code:63764-4301
Mailing Address - Country:US
Mailing Address - Phone:636-477-3280
Mailing Address - Fax:636-477-3241
Practice Address - Street 1:702 HIGHWAY 34 W
Practice Address - Street 2:
Practice Address - City:MARBLE HILL
Practice Address - State:MO
Practice Address - Zip Code:63764-4301
Practice Address - Country:US
Practice Address - Phone:573-238-2614
Practice Address - Fax:573-238-9835
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO102069408Medicaid
MO102069408Medicaid