Provider Demographics
NPI:1730337114
Name:FULL POTENTIAL RESIDENTIAL SERVICES, LLC
Entity type:Organization
Organization Name:FULL POTENTIAL RESIDENTIAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEMETRA
Authorized Official - Middle Name:EVON
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:LIC SOCIAL WORKER
Authorized Official - Phone:314-839-9157
Mailing Address - Street 1:2335 INDIANCUP DR
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63033-1736
Mailing Address - Country:US
Mailing Address - Phone:314-839-9157
Mailing Address - Fax:
Practice Address - Street 1:8208 PAGE AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63130-1115
Practice Address - Country:US
Practice Address - Phone:314-839-9157
Practice Address - Fax:314-839-9157
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-28
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006031224320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities