Healthcare Provider Details

I. General information

NPI: 1174298483
Provider Name (Legal Business Name): GWD ASSISTED LIVING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2021
Last Update Date: 08/10/2021
Certification Date: 08/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11423 SAINT CHARLES ROCK RD
HAZELWOOD MO
63044-2724
US

IV. Provider business mailing address

11423 SAINT CHARLES ROCK RD
BRIDGETON MO
63044-2724
US

V. Phone/Fax

Practice location:
  • Phone: 314-246-9852
  • Fax:
Mailing address:
  • Phone: 314-246-9852
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MRS. VERNISIA WHITE
Title or Position: BUSINESS OWNER
Credential:
Phone: 314-246-9852