MEDICARE: SOC CARE CENTER, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA0600X	Adult Day Care Clinic/Center

General Provider Information

NPI Number	:	1396309597
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOC CARE CENTER, LLC

Provider Business Mailing Address
First Line	:	4029 GRAVOIS AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63116-3622
Country	:	US
Telephone Number	:	314-696-2396
Fax Number	:	314-696-2426

Provider Business Practice Location Address
First Line	:	4029 GRAVOIS AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63116-3622
Country	:	US
Telephone Number	:	314-696-2396
Fax Number	:	314-696-2426

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MARY JOHNSON
Credential	:
Telephone Number	:	314-696-2396

Provider Enumeration Date	:	04/24/2019
Last Update Date	:	04/24/2019

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