NPIMap

Organization Active NPI

Edgewood Manor Health Care Center, L.L.C.

Doing business as Edgewood Manor Health Care Center

  • Skilled Nursing Facility
  • Raytown, MO
National Provider Identifier
1467072280
Registry record updated Apr 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Skilled Nursing FacilityTaxonomy code 314000000X
Legal business name
EDGEWOOD MANOR HEALTH CARE CENTER, L.L.C.
Doing business as
Edgewood Manor Health Care Center
Practice address
11900 Jessica LN
Raytown, MO 64138-2649
Phone
(816) 358-7858
Fax
(816) 356-7775
NPI assigned
Apr 22, 2020
Last updated
Apr 22, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 22, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Richard J. Destefane
Title
President
Phone
(314) 543-3816

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Skilled Nursing Facility 314000000X Primary

Addresses

Primary practice location

11900 Jessica LN
Raytown, MO 64138-2649

Mailing address

1869 Craig Park CT
Saint Louis, MO 63146-4122
Phone (314) 543-3816

Other names 1

  • Edgewood Manor Health Care Center Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MO

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20200511000519 MO Part A Provider - Skilled Nursing Facility 7214368158 Practice locations: Raytown, MO

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1467072280. Details of each certification follow.

Skilled nursing facility certification: CCN 265425

Legal name
EDGEWOOD MANOR HEALTH CARE CENTER LLC
Doing business as
EDGEWOOD MANOR HEALTH CARE CENTER
Certification status
Active
Provider type (POS)
Nursing home – SNF/NF dual certification
Participating since
Apr 12, 1990
Last certification
Oct 1, 2024
Beds
91
Ownership / control type
Limited Liability Corporation
Multi-facility organization
RELIANT CARE MANAGEMENT COMPANY
Most recent change of ownership
Apr 23, 2020
Organization structure
LLCProprietary
Incorporated
Mar 4, 2020 in MO
Enrollment address
11900 Jessica LN
Raytown, MO 64138-2649
Nursing home name
EDGEWOOD MANOR HEALTH CARE CENTER
Affiliated entity
RELIANT CARE MANAGEMENT

Care Compare: Nursing home

Medicare Care Compare
Listed as
Edgewood Manor Health Care CenterCCN 265425 · All quality measures
Overall star rating
1 of 5
Health inspections
1 of 5
Staffing
1 of 5
Quality measures
3 of 5
Type
Medicare and Medicaid
Ownership
For profit - Limited Liability company
Certified
Apr 12, 1990
Medicare certification status
ActiveFrom the Provider of Services file
Certified beds
9175.3 residents per day on average
Chain
Reliant Care Management34 facilities in the chain
Abuse citation
Cited for abuse (Care Compare abuse icon)
Penalties (3 years)
5Fines totaling $135,307

Processed by Care Compare on Aug 1, 2026.

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 5

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
RCG Inc Organization, Saint Louis, MO Corporation 5% Or Greater Indirect Ownership Interest Mar 4, 2020 0.01%
Richard J Destefane Individual Corporate OfficerPresident Mar 4, 2020 100%
OtherPresident and Secretary Mar 4, 2020
Reliant Care Group LLC Organization, Saint Louis, MO LLC 5% Or Greater Direct Ownership Interest Mar 4, 2020 100%
Reliant Care Management Company LLC Organization, Saint Louis, MO LLC Operational/Managerial Control Apr 24, 2020
Kimpton C Hopkins Individual W-2 Managing EmployeeAdministrator Apr 24, 2020 100%

Facilities with the same owner 33

Facilities that share an organizational owner with 5% or greater ownership or operational control.

View all 33

Practitioners & affiliated clinicians

Practitioners 5

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

Affiliated clinicians 1

Clinicians who list this facility as an affiliation in Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1587513600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1587513600000",
    "number": "1467072280",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1869 CRAIG PARK CT",
            "city": "SAINT LOUIS",
            "state": "MO",
            "postal_code": "631464122",
            "telephone_number": "314-543-3816",
            "fax_number": "314-226-1736"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "11900 JESSICA LN",
            "city": "RAYTOWN",
            "state": "MO",
            "postal_code": "641382649",
            "telephone_number": "816-358-7858",
            "fax_number": "816-356-7775"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EDGEWOOD MANOR HEALTH CARE CENTER, L.L.C.",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-04-22",
        "last_updated": "2020-04-22",
        "certification_date": "2020-04-22",
        "status": "A",
        "authorized_official_last_name": "DESTEFANE",
        "authorized_official_first_name": "RICHARD",
        "authorized_official_middle_name": "J.",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "314-543-3816"
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Edgewood Manor Health Care Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Raytown, MO

Sources for this page

Verify at the official NPI Registry.