Healthcare Provider Details

I. General information

NPI: 1104420686
Provider Name (Legal Business Name): ABO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/25/2020
Last Update Date: 11/25/2020
Certification Date: 11/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11429 SAINT CHARLES ROCK RD
BRIDGETON MO
63044-2724
US

IV. Provider business mailing address

11429 SAINT CHARLES ROCK RD
BRIDGETON MO
63044-2724
US

V. Phone/Fax

Practice location:
  • Phone: 314-830-6400
  • Fax: 314-830-6405
Mailing address:
  • Phone: 314-830-6400
  • Fax: 314-830-6405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SHARON PAYNES
Title or Position: DIRECTOR
Credential:
Phone: 314-830-6400