Healthcare Provider Details

I. General information

NPI: 1164602413
Provider Name (Legal Business Name): SHELA L. MEYERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2007
Last Update Date: 06/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 GRAND AVE
FESTUS MO
63028-1842
US

IV. Provider business mailing address

204 GRAND AVE
FESTUS MO
63028-1842
US

V. Phone/Fax

Practice location:
  • Phone: 636-933-0662
  • Fax:
Mailing address:
  • Phone: 636-933-0662
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311Z00000X
TaxonomyCustodial Care Facility
License Number032503
License Number StateMO

VIII. Authorized Official

Name: SHELA MEYERS
Title or Position: OWNER
Credential:
Phone: 636-933-0662