Provider Demographics
NPI:1487715793
Name:THE WOODLANDS OF MARYLAND HEIGHTS LLC
Entity type:Organization
Organization Name:THE WOODLANDS OF MARYLAND HEIGHTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMEBER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:J
Authorized Official - Last Name:RILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-349-2311
Mailing Address - Street 1:1749 GILSINN LN
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026-2003
Mailing Address - Country:US
Mailing Address - Phone:636-349-2311
Mailing Address - Fax:636-349-6491
Practice Address - Street 1:3201 PARKWOOD LN
Practice Address - Street 2:
Practice Address - City:MARYLAND HEIGHTS
Practice Address - State:MO
Practice Address - Zip Code:63043-1334
Practice Address - Country:US
Practice Address - Phone:314-291-5911
Practice Address - Fax:314-291-3576
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RILEY SPENCE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-12
Last Update Date:2014-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO101475903Medicaid
MO265523Medicare Oscar/Certification