Organization
MMA HEALTHCARE OF VIBURNUM, INC.
Active
Other names
Stonecrest Healthcare
Organization subpart
No
Provider details
NPI number
Authorized official
RICHARD J. DESTEFANE (PRESIDENT)
(314) 543-3816
Entity
Organization
Contact information
Practice address
2 HIGHWAY Y, VIBURNUM, MO 65566-9701
(573) 244-3171
(573) 244-3112
Mailing address
1869 CRAIG PARK CT, SAINT LOUIS, MO 63146-4122
(314) 543-3800
(314) 543-3880
Taxonomy
Speciality
Code
Description
License number
State
314000000X
Skilled Nursing Facility
032452
MO
314000000X
Skilled Nursing Facility
Primary
038104
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
103060604
—
MO
Enumeration date
05/27/2006
Last updated
11/08/2019
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