Healthcare Provider Details

I. General information

NPI: 1154788156
Provider Name (Legal Business Name): PROMISE MOBILITY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2016
Last Update Date: 02/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 S NEWSTEAD AVE
SAINT LOUIS MO
63108-2213
US

IV. Provider business mailing address

5 S NEWSTEAD AVE
SAINT LOUIS MO
63108-2213
US

V. Phone/Fax

Practice location:
  • Phone: 314-302-4908
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. CHARLES H FELKER
Title or Position: CEO
Credential:
Phone: 314-302-4908