Healthcare Provider Details

I. General information

NPI: 1578757274
Provider Name (Legal Business Name): THE MARY CULVER HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2007
Last Update Date: 09/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 W WASHINGTON AVE
KIRKWOOD MO
63122-3916
US

IV. Provider business mailing address

221 W WASHINGTON AVE
KIRKWOOD MO
63122-3916
US

V. Phone/Fax

Practice location:
  • Phone: 314-966-6034
  • Fax: 314-966-5462
Mailing address:
  • Phone: 314-966-6034
  • Fax: 314-966-5462

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number12462802
License Number StateMO

VIII. Authorized Official

Name: MS. ROBBIE L ROSSI
Title or Position: BUSINESS MANAGER
Credential:
Phone: 314-966-6034