Healthcare Provider Details

I. General information

NPI: 1164235362
Provider Name (Legal Business Name): INTERFAITH RESIDENCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2025
Last Update Date: 12/29/2025
Certification Date: 12/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 N JEFFERSON AVE
SAINT LOUIS MO
63106-2222
US

IV. Provider business mailing address

1101 N JEFFERSON AVE
SAINT LOUIS MO
63106-2222
US

V. Phone/Fax

Practice location:
  • Phone: 314-535-1919
  • Fax: 314-535-0909
Mailing address:
  • Phone: 314-535-1919
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: OPAL JONES
Title or Position: PRESIDENT & CEO
Credential:
Phone: 314-535-1919