Healthcare Provider Details

I. General information

NPI: 1568582583
Provider Name (Legal Business Name): L & J RESIDENTIAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4985 HIGHWAY D
FARMINGTON MO
63640-7244
US

IV. Provider business mailing address

PO BOX 251
SAINT PETERS MO
63376-0005
US

V. Phone/Fax

Practice location:
  • Phone: 537-759-6304
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311Z00000X
TaxonomyCustodial Care Facility
License Number031382
License Number StateMO

VIII. Authorized Official

Name: DAVID L NOLTING
Title or Position: MANAGER
Credential:
Phone: 573-756-3047