Healthcare Provider Details

I. General information

NPI: 1558652172
Provider Name (Legal Business Name): WINDHAM ENTERPRISES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2011
Last Update Date: 04/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2032 DORSETT VLG
MARYLAND HEIGHTS MO
63043-2208
US

IV. Provider business mailing address

2032 DORSETT VLG
MARYLAND HEIGHTS MO
63043-2208
US

V. Phone/Fax

Practice location:
  • Phone: 314-542-6050
  • Fax: 314-542-6026
Mailing address:
  • Phone: 314-542-6050
  • Fax: 314-542-6026

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number936
License Number StateMO

VIII. Authorized Official

Name: MRS. TAMARA ELAINE WINDHAM
Title or Position: OWNER
Credential:
Phone: 314-839-9199