Healthcare Provider Details

I. General information

NPI: 1508056425
Provider Name (Legal Business Name): MIZPAH ASSISTED LIVING SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2007
Last Update Date: 07/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11325 SAINT CHARLES ROCK RD
BRIDGETON MO
63044-2722
US

IV. Provider business mailing address

11325 SAINT CHARLES ROCK RD
BRIDGETON MO
63044-2722
US

V. Phone/Fax

Practice location:
  • Phone: 314-209-1177
  • Fax: 314-738-0777
Mailing address:
  • Phone: 314-209-1177
  • Fax: 314-738-0777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number032466
License Number StateMO

VIII. Authorized Official

Name: MS. JULIE KLEIN
Title or Position: ADMINISTRATOR
Credential:
Phone: 314-209-1177