Healthcare Provider Details

I. General information

NPI: 1851950943
Provider Name (Legal Business Name): UNDER GRACE ADULT DAY PROGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2019
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4202 BONFILS DR
BRIDGETON MO
63044-1903
US

IV. Provider business mailing address

9191 W FLORISSANT AVE STE 200B
SAINT LOUIS MO
63136-1413
US

V. Phone/Fax

Practice location:
  • Phone: 314-391-9415
  • Fax: 314-254-7349
Mailing address:
  • Phone: 314-391-9415
  • Fax: 314-254-7349

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: TASHAUNA PARKER
Title or Position: DIRECTOR
Credential:
Phone: 314-391-9415