Healthcare Provider Details

I. General information

NPI: 1811815483
Provider Name (Legal Business Name): CANOPY PACIFIC BH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2026
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2510 SPRING VALLEY RD
PACIFIC MO
63069-2723
US

IV. Provider business mailing address

9433 OLIVE BLVD # 100
SAINT LOUIS MO
63132-3132
US

V. Phone/Fax

Practice location:
  • Phone: 732-994-8956
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: MARTIN ZELCER
Title or Position: PRESIDENT
Credential:
Phone: 732-994-8956