Healthcare Provider Details

I. General information

NPI: 1548308778
Provider Name (Legal Business Name): NORTHERNSTAR ADULT DAYCARE CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12916 NEW HALLS FERRY RD
FLORISSANT MO
63033-4035
US

IV. Provider business mailing address

12916 NEW HALLS FERRY RD
FLORISSANT MO
63033-4035
US

V. Phone/Fax

Practice location:
  • Phone: 314-837-3494
  • Fax: 314-837-3447
Mailing address:
  • Phone: 314-837-3494
  • Fax: 314-837-3447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number626
License Number StateMO

VIII. Authorized Official

Name: MRS. JACQUELYN MARIE HUTSON
Title or Position: DIRECTOR
Credential: RN
Phone: 314-837-3494