Healthcare Provider Details

I. General information

NPI: 1861549412
Provider Name (Legal Business Name): BON VIVANT ADULT DAY CLUB L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1525 BOWLES AVE. STE A
FENTON MO
63026
US

IV. Provider business mailing address

1525 BOWLES AVENUE SUITE A
FENTON MO
63026
US

V. Phone/Fax

Practice location:
  • Phone: 636-343-1600
  • Fax: 636-343-1496
Mailing address:
  • Phone: 636-343-1600
  • Fax: 636-343-1496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number652
License Number StateMO

VIII. Authorized Official

Name: DENISE MAUREEN HAMPTON
Title or Position: ASSISTANT ADMINISTRATOR
Credential:
Phone: 636-343-1600