NPIMap

Organization Active NPI

North Village Park, LLC

  • Skilled Nursing Facility
  • Moberly, MO
National Provider Identifier
1821085655
Registry record updated May 30, 2013
On this page

Key facts

NPPES NPI Registry
Primary specialty
Skilled Nursing FacilityTaxonomy code 314000000X
Legal business name
NORTH VILLAGE PARK, LLC
Practice address
2041 Silva LN
Moberly, MO 65270-3658
Phone
(660) 263-1894
Fax
(660) 263-0751
NPI assigned
Oct 6, 2005
Last updated
May 30, 2013By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 30, 2013

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

Authorized official

Name
Mr. Ashwin Dundoo
Title
Finance
Phone
(314) 543-3800

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Skilled Nursing Facility 314000000X Primary

Addresses

Primary practice location

2041 Silva LN
Moberly, MO 65270-3658

Mailing address

1869 Craig Park CT
Saint Louis, MO 63146-4122
Phone (314) 543-3800

Other identifiers 1

IdentifierTypeStateIssuer
102561404MedicaidMO

Other names 1

  • North Village Park Other name

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20091202000653 MO Part A Provider - Skilled Nursing Facility 9931248390 Practice locations: Moberly, MO

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1821085655. Details of each certification follow.

Skilled nursing facility certification: CCN 265330

Legal name
NORTH VILLAGE PARK, LLC
Doing business as
NORTH VILLAGE PARK
Certification status
Active
Provider type (POS)
Nursing home – SNF/NF dual certification
Participating since
Jul 1, 1988
Last certification
Nov 20, 2023
Beds
184 (183 certified)
Ownership / control type
Limited Liability Corporation
Multi-facility organization
Reliant Care Mgmt LLC
Organization structure
LLCProprietary
Enrollment address
2041 Silva LN
Moberly, MO 65270-3658
Nursing home name
NORTH VILLAGE PARK
Affiliated entity
RELIANT CARE MANAGEMENT

Care Compare: Nursing home

Medicare Care Compare
Listed as
North Village ParkCCN 265330 · All quality measures
Overall star rating
1 of 5
Health inspections
1 of 5
Staffing
1 of 5
Quality measures
2 of 5
Type
Medicare and Medicaid
Ownership
For profit - Limited Liability company
Certified
Jul 1, 1988
Medicare certification status
ActiveFrom the Provider of Services file
Certified beds
183168.6 residents per day on average
Chain
Reliant Care Management34 facilities in the chain
Special focus status
SFF Candidate
Abuse citation
Cited for abuse (Care Compare abuse icon)
Penalties (3 years)
17Fines totaling $543,649

Processed by Care Compare on Aug 1, 2026.

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 8

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, Holding company, Owned by another organization or individual Indirect Ownership Interest Sep 28, 2018 0.01%
Richard J Destefane Individual Corporate OfficerPresident Jan 6, 1998 100%
Indirect Ownership Interest Mar 1, 2018 100%
Richard J Destefane Revocable Living Trust Organization, Saint Louis, MO Indirect Ownership Interest Mar 1, 2018 100%
Reliant Care Group LLC Organization, Saint Louis, MO LLC, Holding company, Owned by another organization or individual Indirect Ownership Interest Sep 28, 2018 100%
Reliant Care Management Company LLC Organization, Saint Louis, MO LLC, Management services company, Chain home office Operational/Managerial Control Sep 28, 1989
Adp of the SNF Sep 18, 2025
Abdullah Arshad Individual Operational/Managerial Control Sep 15, 2024
Adp of the SNF Sep 15, 2024
Roystan Pais Individual Operational/Managerial Control Jul 2, 2025
Adp of the SNF Jul 2, 2025
RC Tier Properties, L.L.C. Organization, Saint Louis, MO LLC, Holding company, Owned by another organization or individual Direct Ownership Interest Sep 28, 2018 100%

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Facilities with the same owner 32

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

View all 32

Practitioners & affiliated clinicians

Practitioners 3

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": "1128556800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1369872000000",
    "number": "1821085655",
    "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": "314-543-3800",
            "fax_number": "314-543-3880"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2041 SILVA LN",
            "city": "MOBERLY",
            "state": "MO",
            "postal_code": "652703658",
            "telephone_number": "660-263-1894",
            "fax_number": "660-263-0751"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NORTH VILLAGE PARK, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-10-06",
        "last_updated": "2013-05-30",
        "status": "A",
        "authorized_official_last_name": "DUNDOO",
        "authorized_official_first_name": "ASHWIN",
        "authorized_official_title_or_position": "FINANCE",
        "authorized_official_telephone_number": "314-543-3800",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "102561404",
            "state": "MO"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "North Village Park",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Moberly, MO

Sources for this page

Verify at the official NPI Registry.