Provider Demographics
NPI:1861782898
Name:N/A
Entity type:Organization
Organization Name:N/A
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:HOME AID
Authorized Official - Prefix:MS
Authorized Official - First Name:GLORIA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:PATRICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-401-1466
Mailing Address - Street 1:1318 PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:PAGEDALE
Mailing Address - State:MO
Mailing Address - Zip Code:63133-1036
Mailing Address - Country:US
Mailing Address - Phone:314-401-1466
Mailing Address - Fax:
Practice Address - Street 1:1318 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63133-1036
Practice Address - Country:US
Practice Address - Phone:314-401-1466
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-11
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO07397218320600000X, 320700000X, 323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities